AV synchronous septal pacing

ABSTRACT

An implantable medical system may provide atrioventricular synchronous pacing using the ventricular septal wall. The system may include a ventricular electrode coupled to an intracardiac housing or a first medical lead implantable in the ventricular septal wall of the patient&#39;s heart to deliver cardiac therapy to or sense electrical activity of the left ventricle of the patient&#39;s heart and a right atrial electrode coupled to a leadlet or second medical lead to deliver cardiac therapy to or sense electrical activity of the right atrium of the patient&#39;s heart. A right ventricular electrode may be coupled to the intracardiac housing or the first medical lead and implantable in the ventricular septal wall of the patient&#39;s heart to deliver cardiac therapy to or sense electrical activity of the right ventricle of the patient&#39;s heart.

The present technology is related generally to implantable medicalsystems and methods and, in particular, to synchronous pacing of apatient's heart.

The cardiac conduction system includes the sinus atrial (SA) node, theatrioventricular (AV) node, the bundle of His, bundle branches, andPurkinje fibers. A heartbeat is initiated in the SA node, which may bedescribed as the natural “pacemaker” of the heart. An electrical impulsearising from the SA node causes the atrial myocardium to contract. Thesignal is conducted to the ventricles via the AV node which inherentlydelays the conduction to allow the atria to stop contracting before theventricles begin contracting thereby providing proper AV synchrony. Theelectrical impulse is conducted from the AV node to the ventricularmyocardium via the bundle of His, bundle branches, and Purkinje fibers.

Patients with a conduction system abnormality, such as poor AV nodeconduction or poor SA node function, may receive an implantable medicaldevice (IMD), such as a pacemaker, to restore a more normal heart rhythmand AV synchrony. Some types of IMDs, such as cardiac pacemakers,implantable cardioverter defibrillators (ICDs), or cardiacresynchronization therapy (CRT) devices, provide therapeutic electricalstimulation to a heart of a patient via electrodes on one or moreimplantable endocardial, epicardial, or coronary venous leads that arepositioned in or adjacent to the heart. The therapeutic electricalstimulation may be delivered to the heart in the form of pulses orshocks for pacing, cardioversion, or defibrillation. In some cases, anIMD may sense intrinsic depolarizations of the heart, and control thedelivery of therapeutic stimulation to the heart based on the sensing.

Delivery of therapeutic electrical stimulation to the heart can beuseful in addressing cardiac conditions such as ventricular dyssynchronythat may occur in patients. Ventricular dyssynchrony may be described asa lack of synchrony or a difference in the timing of contractions indifferent ventricles of the heart. Significant differences in timing ofcontractions can reduce cardiac efficiency. CRT, delivered by an IMD tothe heart, may enhance cardiac output by resynchronizing theelectromechanical activity of the ventricles of the heart. CRT issometimes referred to as “triple chamber pacing” because CRT deliverspacing to three chambers, namely, the right atrium, right ventricle, andleft ventricle.

Cardiac arrhythmias may be treated by delivering electrical shocktherapy for cardioverting or defibrillating the heart in addition tocardiac pacing, for example, from an ICD, which may sense a patient'sheart rhythm and classify the rhythm according to an arrhythmiadetection scheme in order to detect episodes of tachycardia orfibrillation. Arrhythmias detected may include ventricular tachycardia(VT), fast ventricular tachycardia (FVT), ventricular fibrillation (VF),atrial tachycardia (AT) and atrial fibrillation (AT). Anti-tachycardiapacing (ATP), a painless therapy, can be used to treat ventriculartachycardia (VT) to substantially terminate many monomorphic fastrhythms. While ATP is painless, ATP may not deliver effective therapyfor all types of VTs. For example, ATP may not be as effective forpolymorphic VTs, which has variable morphologies. Polymorphic VTs andventricular fibrillation (VFs) can be more lethal and may requireexpeditious treatment by shock.

Dual chamber medical devices are available that include a transvenousatrial lead carrying electrodes that may be placed in the right atriumand a transvenous ventricular lead carrying electrodes that may beplaced in the right ventricle via the right atrium. The dual chambermedical device itself is generally implanted in a subcutaneous pocketand the transvenous leads are tunneled to the subcutaneous pocket. Adual chamber medical device may sense atrial electrical signals andventricular electrical signals and can provide both atrial pacing andventricular pacing as needed to promote a normal heart rhythm and AVsynchrony. Some dual chamber medical devices can treat both atrial andventricular arrhythmias.

Intracardiac medical devices, such as a leadless pacemaker, have beenintroduced or proposed for implantation entirely within a patient'sheart, eliminating the need for transvenous leads. A leadless pacemakermay include one or more electrodes on its outer housing to delivertherapeutic electrical signals and/or sense intrinsic depolarizations ofthe heart. Intracardiac medical devices may provide cardiac therapyfunctionality, such as sensing and pacing, within a single chamber ofthe patient's heart. Single chamber intracardiac devices may also treateither atrial or ventricular arrhythmias or fibrillation. Some leadlesspacemakers are not intracardiac and may be positioned outside of theheart and, in some examples, may be anchored to a wall of the heart viaa fixation mechanism.

In some patients, single chamber devices may adequately address thepatient's needs. However, single chamber devices capable of only singlechamber sensing and therapy may not fully address cardiac conductiondisease or abnormalities in all patients, for example, those with someforms of AV dyssynchrony.

SUMMARY

The techniques of this disclosure generally relate to implantablemedical systems and methods for synchronous pacing of a patient's heartusing the ventricular septal wall. These techniques may facilitate areduction in possible infections and facilitate ease of implantation forcardiac therapy, especially cardiac resynchronization therapy, by usingfewer leads than existing leaded systems. Implantable medical systemsmay include a right-atrial electrode and a ventricular electrode andprovide dual- or triple-chamber pacing of the patient's heart. At leastone of the electrodes may be coupled to a leadlet, e.g., extendingacross or through the tricuspid valve. The ventricular electrode maypace the left-ventricular septal wall. A right ventricular electrode mayalso be included on the same device as the ventricular electrode. Somesystems may provide dual- or triple-chamber pacing using an intracardiacdevice and, in some cases, only one intracardiac device. Some of theillustrative implantable medical systems may provide such pacing withoutneeding to create a subcutaneous pocket or without using a separatedevice having leads.

In one aspect, the present disclosure provides a leadless implantablemedical device for a patient's heart includes an intracardiac housingimplantable in the right ventricle of the patient's heart, a leadletcoupled to the intracardiac housing extendable through the tricuspidvalve of the patient's heart into the right atrium of the patient'sheart, and a plurality of electrodes coupled to one or both of theintracardiac housing and the leadlet. The plurality of electrodesincludes a ventricular electrode implantable in the ventricular septalwall of the patient's heart to deliver cardiac therapy to or senseelectrical activity of the left ventricle of the patient's heart. Theplurality of electrodes also includes a right atrial electrode coupledto the leadlet and implantable to deliver cardiac therapy to or senseelectrical activity of the right atrium of the patient's heart. Thedevice further includes a therapy delivery circuit operably coupled tothe plurality of electrodes to deliver cardiac therapy to the patient'sheart, a sensing circuit operably coupled to the plurality of electrodesto sense electrical activity of the patient's heart, and a controllerhaving processing circuitry operably coupled to the therapy deliverycircuit and the sensing circuit. The controller is configured to monitorelectrical activity using one or both of the right atrial electrode andthe ventricular electrode and deliver cardiac therapy based on themonitored electrical activity.

In another aspect, the present disclosure provides an implantablemedical system including an intracardiac housing implantable in a rightventricle of a patient's heart, an implantable medical lead implantableinto the right atrium of a patient's heart, and a plurality ofelectrodes. The plurality of electrodes includes a ventricular electrodecoupled to the intracardiac housing and implantable in the ventricularseptal wall of the patient's heart to deliver cardiac therapy to orsense electrical activity of the left ventricle of the patient's heart.The plurality of electrodes includes a right atrial electrode coupled tothe lead and implantable to deliver cardiac therapy to or senseelectrical activity of the right atrium of the patient's heart. Thesystem further includes a first controller contained in the intracardiachousing and having processing circuitry operably coupled to theventricular electrode. The system further includes a second controllercoupled to the implantable medical lead and having processing circuitryoperably coupled to the right atrial electrode. The first controller isconfigured to wirelessly communicate with the second controller tomonitor electrical activity using one or both of the right atrialelectrode and the ventricular electrode and deliver cardiac therapybased on the monitored electrical activity.

In another aspect, the present disclosure provides an implantablemedical device including an implantable medical housing for a patient'sheart, a first medical lead coupled to the implantable medical housingand implantable in the ventricular septal wall through the rightventricle of the patient's heart, a second medical lead coupled to theimplantable medical housing and implantable in the right atrium of thepatient's heart, and a plurality of electrodes. The plurality ofelectrodes includes a left ventricular electrode coupled to the firstmedical lead and implantable in the ventricular septal wall of thepatient's heart to deliver cardiac therapy to or sense electricalactivity of the left ventricle of the patient's heart, a rightventricular electrode coupled to the first medical lead and implantablein the ventricular septal wall of the patient's heart to deliver cardiactherapy to or sense electrical activity of the right ventricle of thepatient's heart, and a right atrial electrode coupled to the secondmedical lead and implantable to deliver cardiac therapy to or senseelectrical activity of the right atrium of the patient's heart. Thedevice includes a controller having processing circuitry operablycoupled to the ventricular electrode and to the right atrial electrode.The controller is configured to monitor electrical activity using one ormore of the left ventricular electrode, the right ventricular electrode,and the right atrial electrode. The controller is also configured todeliver cardiac therapy based on the monitored electrical activity.

In another aspect, the present disclosure provides a method thatincludes implanting a ventricular electrode coupled to an intracardiachousing or a first medical lead to the ventricular septal wall of apatient's heart to deliver cardiac therapy to or sense electricalactivity of the ventricle of the patient's heart, implanting a rightatrial electrode coupled to a leadlet or a second medical lead in theright atrium of the patient's heart to deliver cardiac therapy to orsense electrical activity of the right atrium of the patient's heart,monitoring electrical activity using the ventricular electrode, theright atrial electrode, or both, and delivering cardiac therapy based onthe monitored electrical activities using at least one of theventricular electrode or the right atrial electrode.

The details of one or more aspects of the disclosure are set forth inthe accompanying drawings and the description below. Other features,objects, and advantages of the techniques described in this disclosurewill be apparent from the description and drawings, and from the claims.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a diagram that illustrates an implantable medical system thatmay be used to provide cardiac therapy to a patient.

FIG. 2 is a schematic diagram that illustrates the implantable medicalsystem of FIG. 1 .

FIG. 3 is a cross-sectional diagram that illustrates a first example ofthe implantable medical system of FIG. 1 including an intracardiacmedical device with a leadlet.

FIG. 4 is a cross-sectional diagram that illustrates a second example ofthe implantable medical system of FIG. 1 including an intracardiacmedical device and a leaded medical device.

FIG. 5 is a cross-sectional diagram that illustrates a third example ofthe implantable medical system of FIG. 1 including a leaded medicaldevice.

FIG. 6 is a perspective diagram that illustrates a first example of anintracardiac implantable medical device for use in the implantablemedical system of FIG. 1 .

FIG. 7 is a perspective diagram that illustrates a second example of anintracardiac implantable medical device for use in the implantablemedical system of FIG. 1 .

FIG. 8 is a schematic diagram that illustrates one example of animplantable medical device for use in the implantable medical system ofFIG. 1 .

FIG. 9 is a diagram of an external apparatus including electrodeapparatus, display apparatus, and computing apparatus for use in theimplantable medical systems and devices of FIGS. 1-8 .

FIGS. 10-11 are diagrams of two examples of external electrode apparatusfor measuring torso-surface potentials for use in the external apparatusof FIG. 9 .

FIG. 12 is a flow diagram of one example of a method for providingcardiac therapy to a patient for use with, for example, the implantablemedical systems, devices, and apparatus of FIGS. 1-11 .

FIG. 13 is a flow diagram of one example of a method for determining animplant location for use with, for example, the implantable medicalsystems of FIGS. 1-8 .

DETAILED DESCRIPTION

The present disclosure provides implantable medical systems and methodsfor synchronous pacing of a patient's heart using the ventricular septalwall, or ventricular septum. Techniques of this disclosure mayfacilitate a reduction in possible infections and facilitate ease ofimplantation for cardiac therapy, especially cardiac resynchronizationtherapy (CRT), by using fewer leads than existing leaded systems.Implantable medical systems may include a right-atrial electrode and aventricular electrode and provide dual- or triple-chamber pacing of thepatient's heart. At least one of the electrodes may be coupled to aleadlet. The ventricular electrode may pace the left-ventricular septalwall. A right ventricular electrode may also be included on the samedevice as the ventricular electrode. Some systems may provide dual- ortriple-chamber pacing using an intracardiac device and, in some cases,only one intracardiac device. Some of the illustrative implantablemedical systems may provide such pacing without needing to create asubcutaneous pocket or without using a separate device having leads.

As used herein, the term “or” is generally employed in its inclusivesense, for example, to mean “and/or” unless the context clearly dictatesotherwise. The term “and/or” means one or all the listed elements or acombination of at least two of the listed elements.

The terms “coupled” or “connected” refer to elements being attached toeach other either directly (i.e., in direct contact with each other) orindirectly (i.e., having one or more elements between and attaching thetwo elements). Either term may be modified by “operatively” and“operably,” which may be used interchangeably, to describe that thecoupling or connection is configured to allow the components to interactto carry out functionality described in this disclosure or known to oneskilled in the art having the benefit of this disclosure.

Reference will now be made to the drawings, which depict one or moreaspects described in this disclosure. However, it will be understoodthat other aspects not depicted in the drawings fall within the scope ofthis disclosure. Like numbers used in the figures refer to likecomponents, steps, and the like. However, it will be understood that theuse of a reference character to refer to an element in a given figure isnot intended to limit the element in another figure labeled with thesame reference character. In addition, the use of different referencecharacters to refer to elements in different figures is not intended toindicate that the differently referenced elements cannot be the same orsimilar.

FIGS. 1-2 show one example of an implantable medical system that may beused to provide single- or multiple-chamber pacing to deliver cardiactherapy to a patient. FIG. 1 illustrates some examples of variouslocations for devices or components of the system relative to thepatient, and FIG. 2 illustrates a schematic depiction of the system andthe patient.

As illustrated, an implantable medical system 100 may be coupled to thebody of a patient 102. In general, the system 100 may monitor electricalactivity, or other activity, of the heart 104 of the patient 102 (or thepatient's heart) and may deliver cardiac therapy based on the monitoredelectrical activity. The system 100 may provide various types of cardiactherapy, such as CRT using multiple-chamber pacing, for example, dual-or triple-chamber synchronous pacing, using one or more of the devicesor components in the system 100. In particular, the system 100 maydeliver atrioventricular (AV) synchronous pacing to two or more chambersof the heart 104. In one example, the system 100 may deliver pacing toeach of the left ventricle (LV), the right ventricle (RV), and the rightatrium (RA) to facilitate, e.g., three-chamber synchronous pacing.

The system 100 may include any number of components to deliver AVsynchronous pacing such as one or more of an intracardiac implantablemedical device 106 (or intracardiac IMD), a leaded implantable medicaldevice 108 (or leaded IMD), an extravascular implantable medical device110 (or extravascular IMD), and an external apparatus 112. In general,one or more of these devices include one or more electrodes. One or moreof these devices of the system 100 may be capable of, individually orcooperatively, monitoring electrical activity of the heart 104 anddelivering cardiac therapy based on the monitored electrical activity.

The intracardiac IMD 106 may be implanted in one or more chambers of theheart 104. As used herein, an “intracardiac” device refers to a deviceconfigured to be implanted entirely within the heart 104. In oneexample, the intracardiac IMD 106 is implanted in the RV of the heart104.

The intracardiac IMD 106 may be described as a leadless IMD. As usedherein, a “leadless” device refers to a device being free of a leadextending out of the heart 104. In other words, a leadless device mayhave a lead that does not extend from outside of the patient's heart toinside of the patient's heart. Some leadless devices may be introducedthrough a vein, but once implanted, the device is free of, or may notinclude, any transvenous lead and may be configured to provide cardiactherapy without using any transvenous lead. In one example, a leadlessdevice implanted in the RV, in particular, does not use a lead tooperably connect to an electrode in the ventricle when a housing of thedevice is positioned in the RV.

One or more electrodes may be directly or indirectly coupled to anintracardiac housing of the intracardiac IMD 106. One or more of theelectrodes may be leadless. As used herein, a “leadless” electroderefers to an electrode operably coupled to a device being free of alead, or without using a lead, extending between the electrode and thehousing of the device.

The intracardiac IMD 106 may include one or more leadlets. As usedherein, the term “leadlet” refers to an elongate structure that extendsfrom a housing of a device implanted in the patient's heart 104 andremains within the patient's heart. In other words, a leadlet does notextend outside of the patient's heart 104. In some cases, a leadlet mayextend from one chamber of the heart 104 to another chamber of theheart. For example, a proximal end of a leadlet may be coupled to thehousing of an intracardiac device implanted in the RV and a body of theleadlet may extend through the tricuspid valve such that a distal end ofthe leadlet is positioned or implanted in the RA.

The leaded IMD 108 includes one or more implantable medical leadscoupled to an implantable medical housing of the leaded IMD and mayinclude one or more electrodes implantable in the heart 104. The one ormore electrodes may be directly or indirectly coupled to the housing ofthe leaded IMD 108. For example, one or more of the electrodes may beleaded, or indirectly coupled to the housing by a lead, to the housingof the leaded IMD 108. Any suitable type of leaded IMD 108 may be used,such as a leaded pacemaker.

The one or more electrodes may be implanted in one or more chambers ofthe heart 104. In one example, the leaded IMD 108 may include, or have,an RA electrode implanted in the RA of the heart 104 via an RA lead. Inanother example, the leaded IMD 108 may include, or have, an RA leadcoupled to an RA electrode implantable in the RA. Further, the leadedIMD 108 may include, or have, a RV lead coupled to an RV electrodeimplanted in the RV and an LV electrode implanted in the LV.

The housing, or can, of the leaded IMD 108 may be implanted in anextravascular location outside of the heart 104. For example, thehousing of the leaded IMD 108 may be implanted in a subcutaneous pocketof the patient 102. In this manner, when implanted, portions of theleaded IMD 108 may be positioned in the heart 104 and other portions ofthe leaded IMD may be positioned outside the heart.

The extravascular IMD 110 is implanted in an extravascular locationoutside of the heart 104. For example, the extravascular IMD 110 may beimplanted in a subcutaneous pocket of the patient 102. The extravascularIMD 110 may include a housing, or can, and may include one or moreleads. Typically, the extravascular IMD 110 does not include a portionthat extends into the heart 104. Any suitable type of extravascular IMD110 may be used, which may include or be described as an extravascularimplantable cardioverter defibrillator (EVICD) or a subcutaneous device(SD).

The extravascular IMD 110 may provide particular types of cardiactherapy to the heart 104. For example, the intracardiac IMD 106 orleaded IMD 108 may wirelessly communicate with the extravascular IMD 110to trigger shock therapy (e.g., defibrillation) performed using theextravascular IMD. Wireless communication between the IMDs 106, 108 andthe IMD 110 may use a distinctive, signaling, or triggering electricalpulse provided by an RA electrode of the intracardiac IMD 106 or leadedIMD 108 that conducts through the patient's tissue and is detectable bythe extravascular IMD 110. Further, such wireless communication may usea communication interface, which may include an antenna, of theintracardiac IMD 106 or the leaded IMD 108 to provide electromagneticradiation that propagates through patient's tissue and is detectable,for example, using a communication interface, which may also include anantenna, of the extravascular IMD 110.

The external apparatus 112 may include one or more components tofacilitate evaluation of various implantation locations (e.g., spatiallocation, implant depth, etc.) and/or pacing settings (e.g., pulsewidth, pulse timing, pulse amplitude, etc.). For example, implantationlocation of and/or pacing delivered by one or more electrodes of theintracardiac IMD 106, leaded IMD 108, or extravascular IMD 110 may beevaluated using the external apparatus 112. The external apparatus 112may include one or more of an electrode apparatus, a display apparatus,and a computing apparatus as will be described further herein withrespect to FIGS. 9-11 . In one example, the electrode apparatus of theexternal apparatus 112 may include a plurality of electrodes configuredto provide electrical heterogeneity information (EHI) that may be usedto evaluate the various implantation locations and/or paced settings.

In general, any one or more of the components of the system 100 maycommunicate with one another, e.g., wired or wirelessly. One or more ofthe devices 106, 108, 110 may include a controller having acommunication interface and processing circuitry. For example, theintracardiac IMD 106 may be operably coupled to the leaded IMD 108 orthe extravascular IMD 110 to communicate wirelessly. The leaded IMD 108may be operably coupled to the extravascular IMD 110 to communicatewirelessly. The controller of each device may be operably coupled tovarious other devices and/or components, such as the electrodes of therespective device or apparatus.

In some embodiments, to provide synchronous AV septal pacing, the RAelectrode senses the intrinsic atrial electrical activity or paces theatrium, and the RV and LV electrodes pace the RV and LV respectively ata programmed interval (AV interval) after the atrial sensing or pacingevent for each cardiac cycle. There may be also a programmed electricaldelay between the RV and LV electrodes (VV delay), so that pacing of thetwo ventricles is sequential instead of simultaneous. The extravascularIMD may have additional sensing capabilities for intrinsic atrialelectrical activation and may send an intrabody signal (such as asignaling pulse) to trigger pacing in the ventricle at a programmedtime-interval following the atrial event. The extravascular IMD may alsohave sensing capabilities for ventricular electrical events and coupledwith an extravascular defibrillation lead that can defibrillate ondetection of ventricular tachycardia.

One or more of the components of the system 100 or devices of the system100, such as intracardiac IMD 106, leaded IMD 108, extravascular IMD110, or external apparatus 112, described herein may include acontroller having processing circuitry or processor, such as a centralprocessing unit (CPU), computer, logic array, or other device capable ofdirecting data coming into or out of the system, device, or apparatus.The controller may include one or more computing devices having memory,processing, and communication hardware. The controller may includecircuitry used to couple various components of the controller togetheror with other components operably coupled to the controller. Thefunctions of the controller may be performed by hardware and/or ascomputer instructions on a non-transient computer readable storagemedium.

Processing circuitry of the controller may include any one or more of amicroprocessor, a microcontroller, a digital signal processor (DSP), anapplication specific integrated circuit (ASIC), a field-programmablegate array (FPGA), and/or equivalent discrete or integrated logiccircuitry. In some examples, the processor may include multiplecomponents, such as any combination of one or more microprocessors, oneor more controllers, one or more DSPs, one or more ASICs, and/or one ormore FPGAs, as well as other discrete or integrated logic circuitry. Thefunctions attributed to the controller or processor herein may beembodied as software, firmware, hardware, or any combination thereof.While described herein as a processor-based system, an alternativecontroller could utilize other components, such as relays and timers toachieve the desired results, either alone or in combination with amicroprocessor-based system.

The exemplary systems, devices, apparatus, methods, and otherfunctionality may be implemented using one or more computer programsusing a computing apparatus, which may include one or more processorsand/or memory. Program code and/or logic described herein may be appliedto input data/information to perform functionality described herein andgenerate desired output data/information. The output data/informationmay be applied as an input to one or more other systems, devices,apparatus, and/or methods. In view of the above, it will be readilyapparent that the controller functionality as described herein may beimplemented in any manner known to one skilled in the art having thebenefit of the present disclosure.

The system 100 may be employed in various configurations to providecardiac therapy. For example, the system 100 may utilize the LV side ofthe ventricular septal wall, or ventricular septum, to provide CRT. Inone example, the system 100 may include the intracardiac IMD 106configured to pace both the RV and LV sides of the ventricular septalwall, or RV septum and LV septum, respectively, without usingtransvenous leads or without creating a subcutaneous pocket.

Further, for example, the system 100 including intracardiac IMD 106 maybe configured as a completely intracardiac implantable medical system.In one example, the system 100 may be configured to pace the LV septumwith or without pacing the RV septum. In another example, the housing ofthe intracardiac IMD 106 may be implanted in the RV endocardium with ascrew-in helix to penetrate the RV septum to pace the LV septum or boththe RV and LV septa, which may allow for LV endocardial septal pacingwith an intracardiac pacemaker without exposing the device to the LVblood volume, or LV endocardial blood pool. The intracardiac IMD 106 mayfurther include a leadlet that can be fixated in the right atrium forright atrial sensing/pacing.

In one particular example, the intracardiac IMD 106 of the system 100that is configured to pace the LV septum for CRT may include anintracardiac housing implanted in the endocardial RV septum and a helixor screw-in mechanism for penetrating the ventricular septum with apacing electrode to pace the LV septum. The intracardiac IMD 106 may beconfigured to pace both the RV septum and the LV septum or apex, or justthe LV septum or apex, without exposing an electrode or other componentdirectly to the LV blood volume. The intracardiac IMD 106 may betriggered by another device, such as the leaded IMD 108 or theextravascular IMD 110, that senses electrical activity of the patient'sheart (e.g., P-waves, etc.). The intracardiac IMD 106 may include aleadlet extending through the tricuspid valve from the RV into the RAthat may be fixated to the RA for sensing or pacing of the RA, which maybe described as providing a complete intracardiac DDD-biventricularpacemaker.

In another example, the system 100 may include only the leaded IMD 108.In yet another example, the system 100 may include both the intracardiacIMD 106 and the leaded IMD 108.

FIGS. 3-5 show various examples of configurations of the implantablemedical system 100 including particular examples of one or both of theintracardiac IMD 106 and the leaded IMD 108 to provide single- ormultiple-chamber pacing for cardiac therapy. FIG. 3 illustrates aconfiguration 200 of the system 100 including one example of anintracardiac IMD 202 in the heart 104. FIG. 4 illustrates aconfiguration 250 of the system 100 including one example of anintracardiac IMD 252 and one example of a leaded IMD 254. FIG. 5illustrates a configuration 270 of the system 100 including one exampleof a leaded IMD 272.

As shown in FIG. 3 , the configuration 200 may include an intracardiacIMD 202 having a housing 204 implantable, positioned, or disposed, inthe RV 206 of the heart 104, a leadlet 208 coupled to the housing 204extending from the RV 206 to the RA 210 through the tricuspid valve 212.The intracardiac IMD 202 may include a plurality of electrodes coupledto the intracardiac housing 204 or the leadlet 208. For example, theplurality of electrodes may include one or more of a ventricularelectrode 214 (or LV electrode), an RA electrode 216 (or atrialelectrode), an optional RV electrode 218, and an optional housing-basedelectrode 232 (or common electrode).

The ventricular electrode 214 may be used for sensing or pacing one ofthe ventricles, such as the LV 222 of the heart 104, to provide cardiactherapy. The ventricular electrode 214 may be coupled to the housing 204or even another leadlet (not shown) extending from the housing 204. Theventricular electrode 214 may be implanted in the ventricular septum 220of the heart 104. In particular, the ventricular electrode 214 may beimplantable in the endocardium of the LV 222 in the ventricular septum220, which may also be described as the LV septum. The ventricularelectrode 214 may be implanted through the ventricular septum 220 in theRV 206, or RV septum, into the endocardium of the LV 222.

The RA electrode 216 may be used for sensing or pacing of the RA 210 ofthe heart 104 to deliver cardiac therapy to or sense electrical activityof the RA 210. The RA electrode 216 may be coupled to the leadlet 208.The RA electrode 216 may be implanted in the endocardium of the RA 210,which may facilitate low sensing or pacing thresholds. Alternatively,the RA electrode 216 may implanted to be free floating in the bloodvolume of the RA 210.

The RV electrode 218 may be used for sensing or pacing of the RV 206 ofthe heart 104 to provide cardiac therapy. The RV electrode 218 may becoupled to the housing 204 or even another leadlet (not shown) extendingfrom the housing 204. The RV electrode 218 may be implanted inventricular septum 220 of the heart 104. In particular, the RV electrode218 may be implantable in the endocardium of the RV 206 in theventricular septum 220, which may also be described as the RV septum.

The intracardiac IMD 202 may include a tissue-penetrating electrodeassembly 224 to position one or more electrodes in cardiac tissuecorresponding to the same or adjacent chamber of the heart 104. Anysuitable shape may be used to form the tissue-penetrating electrodeassembly 224 to position the ventricular electrode 214 and the optionalRV electrode 218. For example, the tissue-penetrating electrode assembly224 may include a helix shape or a dart shape.

The tissue-penetrating assembly 224 may be coupled to a distal endportion of the housing 204. The leadlet 208 may be coupled to thehousing 204 on an opposite side (at a proximal end portion) from thetissue-penetrating electrode assembly 224.

The tissue-penetrating electrode assembly 224 may include theventricular electrode 214 and the RV electrode 218. For example, theventricular electrode 214 or the RV electrode 218 may be coupled to thehousing 204 via the tissue-penetrating assembly 224. Thetissue-penetrating electrode assembly 224 may be generally elongate andbe used to be inserted through the RV septum to position the ventricularelectrode 214 for pacing the LV septum. The RV electrode 218 may bedisposed proximal to the ventricular electrode 214 along thetissue-penetrating electrode assembly 224.

In general, the tissue-penetrating electrode assembly 224 does notposition, or deliver, the ventricular electrode 214 into the bloodvolume of the LV 222. For example, the length of the tissue-penetratingelectrode assembly 224 may be sized to prevent penetration into the LVblood volume. In one example, the length of the tissue-penetratingelectrode assembly 224 may be less than the width of the averageventricular septum.

The intracardiac IMD 202 may also include a fixation assembly to secureor attach the housing 204 or the leadlet 208 to tissue of the heart 104.For example, a tissue-penetrating electrode assembly 224 having a helixshape may be described as including or functioning as a fixationassembly. Alternatively, a fixation assembly may be formed separatelyfrom the tissue-penetrating assembly 224, such as separate hook-shapedtines.

The tissue-penetrating electrode assembly 224 may be implanted invarious locations along the ventricular septum 220. In one example, asillustrated, the tissue-penetrating electrode assembly 224 may beimplanted in the ventricular septum 220 proximate to the base 226, orbasal portion, of the heart 104. Implantation proximate to the base 226may allow for dual-bundle sensing and pacing, for example, bypositioning the RV electrode 218 proximate to the right bundle branchand the ventricular electrode 214 proximate to the left bundle branch.In another example, the tissue-penetrating electrode assembly 224 may beimplanted in the ventricular septum 220 proximate to the mid-septalportion of the heart 104. In a further example, the tissue-penetratingelectrode assembly 224 may be implanted in the ventricular septum 220proximate to the apex 230 of the heart 104. Implantation proximate tothe apex 230 may facilitate use of a simple delivery system having fewercurves or changes in direction. In general, implantation in theventricular septum 220 at any of these locations may be less complexthan implantation in other septa of the heart 104 and may furtherfacilitate sensing and pacing using relatively low thresholds comparedto other implantation locations.

The intracardiac IMD 202 may also include a housing-based electrode 232.The housing-based electrode 232 may serve as a common reference for oneor more of the other electrodes.

In general, this configuration 200 of the system 100 may be used tomonitor electrical activity using one or both of the RA electrode 216and the ventricular electrode 214 and may also be used to delivercardiac therapy based on the monitored electrical activity, for example,using a controller contained in the housing 204. For example, thisconfiguration 200 may be used to deliver three-chamber AV synchronouscardiac therapy or CRT for the RA 210, RV 206, and LV 222 using the RAelectrode 216, the RV electrode 218, and the ventricular electrode 214,each operably coupled to the controller.

As shown in FIG. 4 , the configuration 250 may include an intracardiacIMD 252 and a leaded IMD 254. The configuration 250 may have the same orsimilar structure or functionality as configuration 200 of FIG. 3 ,except that configuration 250 includes the leaded IMD 254 instead of aleadlet extending from the intracardiac IMD 252.

The intracardiac IMD 252 may be similar to the intracardiac IMD 202described with respect to FIG. 3 except that the intracardiac IMD 252does not include a leadlet. For example, the intracardiac IMD 252 mayinclude one or more of the housing 204, the ventricular electrode 214,the RV electrode 218, the tissue-penetrating electrode assembly 224, andthe housing-based electrode 232, as described with respect to the IMD202 of FIG. 3 . The intracardiac IMD 252 may be implanted in theventricular septum 220 at any of the base 226, the mid-septal 228, orthe apex 230 of the heart 104.

The leaded IMD 254 may include a housing 256 implantable, positioned, ordisposed, in an extravascular location, an implantable medical lead 258coupled to the housing 256 extending from the extravascular location tothe RA 210 through the superior vena cava 260. The leaded IMD 254 mayinclude one or more electrodes coupled to the housing 256 or the lead258. For example, an RA electrode 216 and a housing-based electrode 264coupled to the lead 258.

The RA electrode 216 may be implanted in the RA 210 of the heart 104.The housing-based electrode 264 may be used as a common referenceelectrode in addition to or as an alternative to housing-based electrode232 on the intracardiac IMD 252.

In general, this configuration 250 of the system 100 may be used tomonitor electrical activity and may also be used to deliver cardiactherapy based on the monitored electrical activity, for example, using afirst controller contained in the housing 204 of the intracardiac IMD252 and a second controller contained in the housing 256 of the leadedIMD 254. For example, the first controller of the intracardiac IMD 252may be configured to wirelessly communicate with the second controllerof leaded IMD 254 to monitor electrical activity using one or both ofthe RA electrode 216 and the ventricular electrode 214.

The controllers may be in operative communication with one another, forexample, using a wireless communication interface or using a signalingpulse to carry out the monitoring of electrical activity and thedelivery of cardiac therapy. For example, this configuration 250 may beused to deliver three-chamber AV synchronous cardiac therapy or CRT forthe RA 210, RV 206, and LV 222 by using the RA electrode 216, the RVelectrode 218, and the LV electrode 214, each operably coupled to therespective first or second controller in wireless communication with oneanother.

As shown in FIG. 5 , the configuration 270 may include a leaded IMD 272.The configuration 270 may have the same or similar structure orfunctionality as configuration 250 of FIG. 4 , except that configuration270 includes a ventricular lead instead of an intracardiac IMD in the RV206. In particular, the leaded IMD 272 is similar to leaded IMD 254described with respect to FIG. 4 except that the leaded IMD 272 furtherincludes a ventricular lead 274. For example, the leaded IMD 272includes a housing 256, an implantable medical lead 258 (or RA lead), anRA electrode 216, and a housing-based electrode 264.

The leaded IMD 272 includes the ventricular lead 274, which may becoupled to the housing 256 and implantable in the ventricular septum220. In particular, the ventricular lead 274 may extend through thesuperior vena cava 260, through the RA 210, through the tricuspid valve212, and into the RV 206. The leaded IMD 254 may include one or moreelectrodes coupled to the housing 256 or the ventricular lead 274. Forexample, a ventricular electrode 214 may be coupled to the ventricularlead 274.

The leaded IMD 272 may include a tissue-penetrating electrode assembly224 coupled to the ventricular lead 274 at a distal end portion of theleaded IMD 272. An RV electrode 218 may also be coupled to thetissue-penetrating electrode assembly 224. The tissue-penetratingelectrode assembly 224 may be implanted in the ventricular septum 220 atany of the base 226, the mid-septal 228, or the apex 230 of the heart104.

In general, this configuration 270 of the system 100 may be used tomonitor electrical activity using one or both of the RA electrode 216and the ventricular electrode 214 and may also be used to delivercardiac therapy based on the monitored electrical activity, for example,using a controller contained in the housing 256. For example, thisconfiguration 270 may be used to deliver three-chamber AV synchronouscardiac therapy or CRT for the RA 210, RV 206, and LV 222 using the RAelectrode 216 coupled to the implantable medical lead 258 and the RVelectrode 218 and the LV electrode 214 each coupled to the ventricularlead 274, each of the electrodes being operably coupled to thecontroller.

FIGS. 6-7 show two examples of intracardiac IMDs that may be used insystem 100 for implantation into the ventricular septum from the RVtoward the LV to provide single- or multiple-chamber pacing for cardiactherapy. Although not shown in FIGS. 6-7 , each of the intracardiac IMDsmay include a leadlet, such as leadlet 208 (FIG. 3 ) coupled to aproximal end region 308 of the intracardiac housing 302 extendingproximally to be implanted in the RA.

FIG. 6 shows a first example of an intracardiac IMD that may be used insystem 100. An intracardiac IMD 300 may be configured to calibratepacing therapy and/or deliver pacing therapy for single or multiplechamber cardiac therapy (e.g., dual- or triple-chamber cardiac therapy).The intracardiac IMD 300 may include a housing 302 having, or defining,an outer sidewall 304, shown as a cylindrical, outer sidewall, extendingfrom a housing distal end region 306 to a housing proximal end region308. The housing 302 may enclose electronic circuitry configured toperform single- or multiple-chamber cardiac therapy, includingelectrical signal sensing and pacing of the ventricular chambers. Adelivery tool interface member 310 may be disposed on or proximate thehousing proximal end region 308.

The intracardiac IMD 300 may include an electrically-insulative distalmember 314 coupled to the housing distal end region 306. Multiplenon-tissue piercing electrodes, or non-tissue penetrating electrodes,may be coupled directly to the insulative distal member 314.

A tissue-penetrating electrode assembly 312 may be coupled to thehousing distal end region 306. The tissue-penetrating electrode assembly312 may extend away from the housing distal end region 306. Thetissue-penetrating electrode assembly 312 may be coaxial with alongitudinal center axis 318 extending along the elongate shape thehousing 302.

The tissue-penetrating electrode assembly 312 may include or beintegrated with a fixation assembly in the form of a helix. Thetissue-penetrating electrode assembly 312 may be described as a helixelectrode assembly.

The tissue-penetrating electrode assembly 312 may include anelectrically insulated shaft 320 and one or more electrodes, such as aventricular electrode 322 (LV electrode) and a ventricular electrode 336(RV electrode), which may be described as tissue-piercing ortissue-penetrating electrodes. The ventricular electrode 322 may bedescribed as a distal cathode ventricular electrode 322, and theventricular electrode 336 may be described as a proximal cathodeventricular electrode 336.

The tissue-penetrating electrode assembly 312 may be described as an“active” fixation assembly. The tissue-penetrating electrode assembly312 may include a helix-shaped, or helical, shaft 320. The helical shaft320 may extend from a shaft distal end region 324 to a shaft proximalend region 326, which may be directly coupled to the insulative distalmember 314. The helical shaft 320 may be coated with an electricallyinsulating material to avoid sensing or stimulation of cardiac tissuealong the shaft length.

The ventricular electrode 322 may be disposed at or proximate to theshaft distal end region 324. The ventricular electrode 336 may bedisposed proximal to the ventricular electrode 322 along the shaft 320closer to the housing 302. In some cases, the ventricular electrode 336is disposed at or proximate to the shaft proximal end region 324.

When using the IMD 300 as a pacemaker for multiple chamber pacing (e.g.,dual or triple chamber pacing) and sensing, the ventricular electrode322 may be used as a cathode electrode and the ventricular electrode 336or the ventricular electrode 316 may be used as a cathode electrode (RVelectrode) each paired with the proximal housing-based electrode 328serving as a common return anode electrode. Alternatively, theventricular electrode 336, the ventricular electrode 316, or thehousing-based electrode 328 may serve as a return anode electrode pairedwith the ventricular electrode 322 (LV electrode) as a cathode forsensing LV signals and delivering LV pacing pulses.

The proximal housing-based electrode 328 may be a ring electrodecircumscribing the housing 302 and may be defined by an uninsulatedportion of the longitudinal outer sidewall 304. Other portions of thehousing 302 not serving as an electrode may be coated with anelectrically insulating material.

The ventricular electrode 316 may be described as a non-tissue piercingelectrode. Multiple non-tissue piercing electrodes may be provided alonga periphery of the insulative distal member 314, peripheral to thetissue-penetrating electrode assembly 312. The insulative distal member314 may define a distal-facing surface 330 of the intracardiac IMD 300and may define a circumferential surface 332 that circumscribes theintracardiac IMD 300 adjacent to the housing longitudinal sidewall 304.As illustrated, six non-tissue piercing electrodes may be spaced apartradially at equal distances along the outer periphery of insulativedistal member 314. In general, one, two, or more non-tissue piercingelectrodes may be provided.

When the ventricular electrode 322 is implanted and positioned in the LVmyocardium in the ventricular septum (or LV septum), the ventricularelectrode 336 may be implanted and positioned in the RV myocardium inthe ventricular septum (or RV septum).

Alternatively, or additionally, when the ventricular electrode 322 isimplanted and positioned in the LV myocardium, at least one ventricularelectrode 316 may be positioned against, in intimate contact with, or inoperative proximity to, an RV tissue surface for delivering pulsesand/or sensing cardiac electrical signals produced by the patient'sheart. For example, non-tissue piercing electrodes may be positioned incontact with RV endocardial tissue for pacing and sensing in the RV whenthe tissue-penetrating electrode assembly 312 is advanced into the RVseptal tissue until the distal tip ventricular electrode 322 ispositioned in direct contact with LV septal tissue, such as the LVmyocardium and/or a portion of the ventricular conduction system.

By providing multiple non-tissue piercing electrodes along the peripheryof the insulative distal member 314, the angle of the tissue-penetratingelectrode assembly 312 and the housing distal end region 306 relative tothe cardiac surface, e.g., the RV endocardial surface, may not berequired to be substantially parallel.

The ventricular electrode 316 may be disposed in one or more recesses334 to be subflush, flush, or raised relative to the housing 302. Thenon-tissue piercing electrodes are shown to each include a first portion316 a extending along the distal-facing surface 330 and a second portion316 b extending along the circumferential surface 332.

FIG. 7 shows a second example of an intracardiac IMD that may be used inthe system 100. An intracardiac IMD 350 that may be configured forcalibrating pacing therapy and/or delivering pacing therapy and includea tissue-penetrating electrode assembly 352. The intracardiac IMD 350may have the same or similar functionality as the intracardiac IMD 300of FIG. 6 except that intracardiac IMD 350 uses a different form oftissue-penetrating electrode assembly and distal housing-basedelectrode.

The tissue-penetrating electrode assembly 352 may include or beintegrated with a fixation assembly in the form of a dart. Thetissue-penetrating electrode assembly 352 may be described as a dartelectrode assembly.

The intracardiac IMD 350 may include a housing 360. The housing 360 maydefine a hermetically sealed internal cavity in which internalcomponents of the intracardiac IMD 350 reside, such as a sensingcircuit, a therapy delivery circuit, a control circuit (or controllerwith processing circuitry), memory, communication interface (ortelemetry circuit), other optional sensors, and a power source. Thehousing 360 may be described as extending between a distal end region362 and a proximal end region 364 in a generally cylindrical shape tofacilitate catheter delivery. Alternatively, the housing 360 may be anyother shape to perform the functionality and utility described herein.The housing 360 may include a delivery tool interface member, e.g., atthe proximal end region 364, for engaging with a delivery tool duringimplantation of the intracardiac IMD 350.

All or a portion of the housing 360 may function as an electrode duringcardiac therapy, for example, in sensing and/or pacing. In the exampleshown, the housing-based electrode 358 is shown to circumscribe aproximal portion of the housing 360. When the housing 360 is formed froman electrically conductive material portions of the housing 360 may beelectrically insulated by a non-conductive material leaving one or morediscrete areas of conductive material exposed to define the proximalhousing-based electrode 358. When the housing 360 is formed from anon-conductive material, an electrically conductive coating or layer maybe applied to one or more discrete areas of the housing 30 to form theproximal housing-based electrode 24. In other examples, the proximalhousing-based electrode 358 may be a component, such as a ringelectrode, that is mounted or assembled onto the housing 360. Theproximal housing-based electrode 358 may be electrically coupled tointernal circuitry of the intracardiac IMD 350, e.g., via theelectrically conductive housing 360 or an electrical conductor when thehousing 360 is a non-conductive material. In the example shown, theproximal housing-based electrode 358 is located nearer to the housingproximal end region 364 than the housing distal end region 362.

The tissue-penetrating electrode assembly 352 may be disposed at thedistal end region 362 of the intracardiac IMD 350. Thetissue-penetrating electrode assembly 352 may include one or moreelectrodes, such as ventricular electrode 366 (or LV electrode) andventricular electrode 370 (or RV electrode) coupled to one or moreshafts 368, or darts, of equal or unequal length.

The shaft 368 may extend distally away from the housing distal endregion 362. The ventricular electrode 366 may be disposed at or near thefree, distal end region of the shaft 368. The ventricular electrode 366may have a conical or hemi-spherical distal tip with a relatively narrowtip diameter (e.g., less than 1 mm) for penetrating into and throughtissue layers without using a sharpened tip or needle-like tip havingsharpened or beveled edges. The ventricular electrode 370 may bedisposed proximal to the ventricular electrode 366 along the shaft 368nearer to the housing 360. In particular, when the ventricular electrode366 is implanted and positioned in the LV myocardium in the ventricularseptum (or LV septum), the ventricular electrode 370 may be implantedand positioned in the RV myocardium in the ventricular septum (or RVseptum).

The shaft 368 may be a normally straight member and may be rigid.Alternatively, the shaft 368 may be described as being relatively stiffbut still possessing limited flexibility in lateral directions. Further,the shaft 368 may be non-rigid to allow some lateral flexing with heartmotion. However, in a relaxed state, when not subjected to any externalforces, the shaft 368 may maintain a straight position as shown to holdthe ventricular electrode 366 spaced apart from the housing distal endregion 362 at least by the longitudinal height of the shaft 368.

The tissue-penetrating electrode assembly 352 may be configured topierce through one or more tissue layers to position the ventricularelectrode 366 within a desired tissue layer, e.g., the ventricularmyocardium. As such, the longitudinal height of the shaft 368 maycorrespond to the expected pacing site depth, and the shaft 368 may havea relatively high compressive strength along its longitudinal axis toresist bending in a lateral or radial direction when pressed against theimplant region.

The intracardiac IMD 350 may include a fixation assembly separate fromthe tissue-penetrating electrode assembly 352. As illustrated, afixation assembly 356 may be operably coupled to the housing 360 that iscouplable to cardiac tissue, such as the RV endocardium. The fixationassembly 356 may include three fixation elements 356 a, 356 b, 356 c areshown. The fixation elements may be described as “tines” having anormally curved position. The tines may be held in a distally extendedposition within a delivery tool. The distal tips of tines may penetratethe heart tissue to a limited depth before elastically curving backproximally into the normally curved position (shown) upon release fromthe delivery tool. Further, the fixation assembly 356 may include one ormore aspects described in, for example, U.S. Pat. No. 9,675,579 (Grubacet al.), issued 13 Jun. 2017, and U.S. Pat. No. 9,119,959 (Rys et al.),issued 1 Sep. 2015, each of which is incorporated herein by reference.

In some examples, the intracardiac IMD 350 includes a distalhousing-based ventricular electrode 354 in addition to, or as analternative to, the ventricular electrode 370. As illustrated, theventricular electrode 354 may include a portion on a distal surface ofthe housing 360 or a portion on the circumferential outer surface of thehousing 360.

When using the IMD 350 as a pacemaker for multiple chamber pacing (e.g.,dual or triple chamber pacing) and sensing, the ventricular electrode366 may be used as a cathode electrode and the ventricular electrode 354or the ventricular electrode 370 may be used as a cathode electrode (RVelectrode) each paired with the proximal housing-based electrode 358serving as a common return anode electrode. Alternatively, theventricular electrode 354, the ventricular electrode 370, or thehousing-based electrode 358 may serve as a return anode electrode pairedwith the ventricular electrode 366 (LV electrode) as a cathode forsensing LV signals and delivering LV pacing pulses.

The tissue-penetrating electrode assembly 352 may define thelongitudinal height of the shaft 368 for penetrating through the RVendocardium in the target implant region and into the LV myocardiumwithout perforating through the ventricular endocardial surface into theLV blood volume. When the longitudinal height of the shaft 368 fullyadvances into the target implant region, the ventricular electrode 366may rest within the LV myocardium, and the ventricular electrode 370 orthe ventricular electrode 354 may be positioned in the RV myocardium orin intimate contact with or close proximity to the RV endocardium,respectively.

FIG. 8 shows one example of a schematic layout of an IMD of the system100, which may be used for one or more of the intracardiac IMD 106, theleaded IMD 108, or the extravascular IMD 110, for example, to providesingle- or multiple-chamber pacing for cardiac therapy. As illustrated,the IMD 400 may include various components, such as a sensing circuit402, a therapy delivery circuit 404, processing circuitry 406 (a controlcircuit or processor) operably coupled to the sensing and therapydelivery circuits, communication interface 408 (a telemetry circuit)operably coupled to the processing circuitry, memory 410 operablycoupled to the processing circuitry, one or more other sensors 412operably coupled to the processing circuitry, and a power source 414operably coupled to the processing circuitry. One or more of thesecomponents may be contained within a housing 420.

In general, the memory 410 may be used to store parameters or otherinformation or data that is predetermined, received, or determined bythe processing circuitry 406 for later retrieval and use by othercomponents of the IMD 400. The power source 414 may provide power to thecircuitry of the IMD 400 including one or more of the components asneeded. The power source 414 may include one or more energy storagedevices, such as one or more rechargeable or non-rechargeable batteries.

The components of IMD 400 may cooperatively monitor atrial orventricular electrical cardiac signals, determine when a cardiac therapyis necessary, and/or deliver electrical pulses to the patient's heartaccording to programmed therapy mode and pulse control parameters. Inparticular, the sensing circuit 402 may be operably coupled to one ormore electrodes to monitor electrical activity of the heart in one ormore of the LV, RV, and RA. For example, the sensing circuit 402 may beoperably coupled to one or more of a first ventricular electrode 422 (LVelectrode), a second ventricular electrode 424 (RV electrode), and anatrial electrode 426 (RA electrode). The sensing circuit 402 may also beoperably coupled to a common reference electrode (not shown), such as ahousing-based electrode.

The sensing circuit 402 may include one or both of an atrial sensingchannel 430 and a ventricular sensing channel 432. The atrial electrode426 may be operably coupled to the atrial sensing channel 430. The firstventricular electrode 422 or the second ventricular electrode 424 may beoperably coupled to the ventricular sensing channel 432. A housing-basedelectrode may be operably coupled to the ventricular sensing channel432.

The therapy delivery circuit 404 may be operably coupled to one or moreelectrodes to deliver cardiac therapy, such as CRT, to one or morechambers of the heart, such as the LV, RV, and RA. For example, thetherapy delivery circuit 404 may be operably coupled to one or more of afirst ventricular electrode 422 (LV electrode), a second ventricularelectrode 424 (RV electrode), and an atrial electrode 426 (RAelectrode). The therapy delivery circuit 404 may also be operablycoupled to a common reference electrode (not shown), such as ahousing-based electrode.

The therapy delivery circuit 404 may include one or both of an atrialpacing channel 440 and a ventricular pacing channel 442. The atrialelectrode 426 may be operably coupled to the atrial pacing channel 440.The first ventricular electrode 422 or the second ventricular electrode424 may be operably coupled to the ventricular pacing channel 442. Ahousing-based electrode may be operably coupled to the ventricularpacing channel 442. The therapy delivery circuit 404 may also be used todeliver communication signals in the form of a pacing signal, forexample, from an extravascular IMD to an intracardiac IMD.

In general, the IMD 400 may be configured to deliver one or more typesof cardiac therapy, such as bradycardia pacing, CRT, post-shock pacing,and/or tachycardia-related therapy, such as ATP, among others. Each ofthe atrial sensing channel 430 and the ventricular sensing channel 432may include cardiac event detection circuitry for detecting P-waves andR-waves, respectively, from the cardiac electrical signals received bythe respective sensing channels. The cardiac event detection circuitrymay be configured to amplify, filter, digitize, and rectify the cardiacelectrical signal received from one or more selectable electrodes toimprove the signal quality for detecting cardiac electrical events. Thecardiac event detection circuitry may include one or more senseamplifiers, filters, rectifiers, threshold detectors, comparators,analog-to-digital converters (ADCs), timers, or other analog or digitalcomponents. A cardiac event sensing threshold, such as a P-wave sensingthreshold and an R-wave sensing threshold, may be automatically adjustedby each respective sensing channel under the control of the processingcircuitry 406, for example, based on timing intervals and sensingthreshold values determined by the processing circuitry 406 or stored inthe memory 410.

Upon detecting a cardiac electrical event based on a sensing thresholdcrossing, the sensing circuit 402 may produce a sensed event signal thatis passed to the processing circuitry 406. For example, the atrialsensing channel 430 may produce a P-wave sensed event signal in responseto a P-wave sensing threshold crossing. The ventricular sensing channel432 may produce an R-wave sensed event signal in response to an R-wavesensing threshold crossing. The sensed event signals may be used by theprocessing circuitry 406 for setting pacing escape interval timers thatcontrol the basic time intervals used for scheduling cardiac pacingpulses. A sensed event signal may trigger or inhibit a pacing pulsedepending on the particular programmed pacing mode. For example, aP-wave sensed event signal received from the atrial sensing channel 430may cause the processing circuitry 406 to inhibit a scheduled atrialpacing pulse and schedule a ventricular pacing pulse at a programmedatrioventricular (AV) pacing interval. If an R-wave is sensed before theAV pacing interval expires, the ventricular pacing pulse may beinhibited. If the AV pacing interval expires before the processingcircuitry 406 receives an R-wave sensed event signal from theventricular sensing channel 432, the processing circuitry 406 may usethe therapy delivery circuit 404 to deliver the scheduled ventricularpacing pulse synchronized to the sensed P-wave.

The atrial pacing channel 440 and the ventricular pacing channel 442 ofthe therapy delivery circuit 404 may each include charging circuitry,one or more charge storage devices, such as one or more low voltageholding capacitors, an output capacitor, and/or switching circuitry thatcontrols when the holding capacitor(s) are charged and discharged acrossthe output capacitor to deliver a pacing pulse to the pacing electrodevector coupled to respective pacing circuits. The ventricular pacingchannel 442 may deliver ventricular pacing pulses, for example, uponexpiration of an AV or VV pacing interval set by the processingcircuitry 406 for providing atrial-synchronized ventricular pacing.

The atrial pacing channel 440 may be configured to deliver atrial pacingpulses. The processing circuitry 406 may set one or more atrial pacingintervals rate. The atrial pacing channel 440 may be controlled todeliver an atrial pacing pulse, for example, if an atrial pacinginterval expires before a P-wave sensed event signal is received fromthe atrial sensing channel. The processing circuitry 406 may start an AVpacing interval in response to a delivered atrial pacing pulse toprovide synchronized multiple-chamber pacing (e.g., dual- ortriple-chamber pacing).

The IMD 400 may include other sensors 412 for sensing information aboutthe patient for use in controlling electrical stimulation therapiesdelivered by the therapy delivery circuit 404. For example, a sensorindicative of a need for increased cardiac output may include a patientactivity sensor, such as an inertial measurement unit (IMU) oraccelerometer to measure motion. In general, information from the one ormore other sensors 412 may be correlated to a physiological function,state, or condition of the patient, such as a patient activity sensor,for use in controlling cardiac therapy.

The communication interface 408 may be used to communicate with otherdevices in the system 100. The communication interface 408 may also beused for receiving parameters to program the processing circuitry 406,which may be stored as data in the memory 410. The communicationinterface 408 may include a transceiver and antenna for wirelesslycommunicating with an external device using radio frequency (RF)communication or other communication protocols. The communicationinterface 408 may be configured to be unidirectional or bi-directional.

FIGS. 9-11 show examples of external apparatus may be used to facilitateimplantation or configuration of the system 100. FIG. 9 depicts oneexample of a system 500 of the external apparatus including electrodeapparatus 510, display apparatus 530, and computing apparatus 540.

The electrode apparatus 510 as shown includes a plurality of electrodesincorporated, or included, within a band wrapped around the chest, ortorso, of a patient 520. The electrode apparatus 510 is operativelycoupled to the computing apparatus 540 (e.g., through one or wiredelectrical connections, wirelessly, etc.) to provide electrical signalsfrom each of the electrodes to the computing apparatus 540 for analysis,evaluation, etc. Electrode apparatus may be described in U.S. Pat. No.9,320,446 entitled “Bioelectric Sensor Device and Methods” and issued onApr. 26, 2016, which is incorporated herein by reference in itsentirety.

Although not described herein, the system 500 may further includeimaging apparatus. The imaging apparatus may be any type of imagingapparatus configured to image, or provide images of, at least a portionof the patient in a noninvasive manner. For example, the imagingapparatus may not use any components or parts that may be located withinthe patient to provide images of the patient except noninvasive tools,such as contrast solution. It is to be understood that the systems,methods, and interfaces described herein may further use imagingapparatus to provide noninvasive assistance to a user (e.g., aphysician) to calibrate and/or deliver a cardiac pacing therapy, tolocate and position a device to deliver cardiac pacing therapy, and/orto locate or select a pacing electrode or pacing vector proximate thepatient's heart for cardiac pacing therapy in conjunction with theevaluation of cardiac pacing therapy.

For example, the systems, methods, and interfaces may provideimage-guided navigation that may be used to navigate leads includingleadless devices, electrodes, leadless electrodes, wireless electrodes,catheters, etc., within the patient's body while also providingnoninvasive cardiac therapy evaluation including determining whether apaced setting is optimal or determining whether one or more selectedparameters are optimal, such as selected location information (e.g.,location information for the electrodes to target a particular locationin the left ventricle). Systems and methods that use imaging apparatusand/or electrode apparatus may be described in U.S. Pat. No. 9,877,789issued on Jan. 30, 2018, and entitled “Implantable Electrode LocationSelection,” U.S. Pat. No. 10,251,555 issued Apr. 9, 2019, and entitled“Implantable Electrode Location Selection,” U.S. Pat. No. 9,924,884issued on Mar. 27, 2018, and entitled “Systems, Methods, and Interfacesfor Identifying Effective Electrodes,” U.S. Pat. No. 10,064,567 issuedon Sep. 4, 2018, and entitled “Systems, Methods, and Interfaces forIdentifying Optical-Electrical Vectors,” each of which is incorporatedherein by reference in its entirety.

Imaging apparatus may be configured to capture x-ray images and/or anyother alternative imaging modality. For example, the imaging apparatusmay be configured to capture images, or image data, using isocentricfluoroscopy, bi-plane fluoroscopy, ultrasound, computed tomography (CT),multi-slice computed tomography (MSCT), magnetic resonance imaging (MM),high frequency ultrasound (HIFU), optical coherence tomography (OCT),intravascular ultrasound (IVUS), two-dimensional (2D) ultrasound, threedimensional (3D) ultrasound, four-dimensional (4D) ultrasound,intraoperative CT, intraoperative MM, etc. Further, it is to beunderstood that the imaging apparatus may be configured to capture aplurality of consecutive images (e.g., continuously) to provide videoframe data. In other words, a plurality of images taken over time usingthe imaging apparatus may provide video frame, or motion picture, data.Additionally, the images may also be obtained and displayed in two,three, or four dimensions. In more advanced forms, four-dimensionalsurface rendering of the heart or other regions of the body may also beachieved by incorporating heart data or other soft tissue data from amap or from pre-operative image data captured by MRI, CT, orechocardiography modalities. Image datasets from hybrid modalities, suchas positron emission tomography (PET) combined with CT, or single photonemission computer tomography (SPECT) combined with CT, could alsoprovide functional image data superimposed onto anatomical data, e.g.,to be used to navigate treatment apparatus proximate target locations(e.g., such as locations within the RV or LV) within the heart or otherareas of interest.

Systems and/or imaging apparatus that may be used in conjunction withthe exemplary systems and method described herein are described in U.S.Pat. App. Pub. No. 2005/0008210 to Evron et al. published on Jan. 13,2005, U.S. Pat. App. Pub. No. 2006/0074285 to Zarkh et al. published onApr. 6, 2006, U.S. Pat. No. 8,731,642 issued May 20, 2014, to Zarkh etal. U.S. Pat. No. 8,861,830 issued Oct. 14, 2014, to Brada et al., U.S.Pat. No. 6,980,675 to Evron et al. issued on Dec. 27, 2005, U.S. Pat.No. 7,286,866 to Okerlund et al. issued on Oct. 23, 2007, U.S. Pat. No.7,308,297 to Reddy et al. issued on Dec. 11, 2011, U.S. Pat. No.7,308,299 to Burrell et al. issued on Dec. 11, 2011, U.S. Pat. No.7,321,677 to Evron et al. issued on Jan. 22, 2008, U.S. Pat. No.7,346,381 to Okerlund et al. issued on Mar. 18, 2008, U.S. Pat. No.7,454,248 to Burrell et al. issued on Nov. 18, 2008, U.S. Pat. No.7,499,743 to Vass et al. issued on Mar. 3, 2009, U.S. Pat. No. 7,565,190to Okerlund et al. issued on Jul. 21, 2009, U.S. Pat. No. 7,587,074 toZarkh et al. issued on Sep. 8, 2009, U.S. Pat. No. 7,599,730 to Hunteret al. issued on Oct. 6, 2009, U.S. Pat. No. 7,613,500 to Vass et al.issued on Nov. 3, 2009, U.S. Pat. No. 7,742,629 to Zarkh et al. issuedon Jun. 22, 2010, U.S. Pat. No. 7,747,047 to Okerlund et al. issued onJun. 29, 2010, U.S. Pat. No. 7,778,685 to Evron et al. issued on Aug.17, 2010, U.S. Pat. No. 7,778,686 to Vass et al. issued on Aug. 17,2010, U.S. Pat. No. 7,813,785 to Okerlund et al. issued on Oct. 12,2010, U.S. Pat. No. 7,996,063 to Vass et al. issued on Aug. 9, 2011,U.S. Pat. No. 8,060,185 to Hunter et al. issued on Nov. 15, 2011, andU.S. Pat. No. 8,401,616 to Verard et al. issued on Mar. 19, 2013, eachof which is incorporated herein by reference in its entirety.

The display apparatus 530 and the computing apparatus 540 may beconfigured to display and analyze data such as, e.g., electrical signals(e.g., electrocardiogram data), cardiac information representative ofone or more of mechanical cardiac functionality and electrical cardiacfunctionality (e.g., mechanical cardiac functionality only, electricalcardiac functionality only, or both mechanical cardiac functionality andelectrical cardiac functionality), etc. Cardiac information may include,e.g., electrical heterogeneity information or electrical dyssynchronyinformation, surrogate electrical activation information or data, etc.that is generated using electrical signals gathered, monitored, orcollected, using the electrode apparatus 510. The computing apparatus540 may be a server, a personal computer, or a tablet computer. Thecomputing apparatus 540 may be configured to receive input from inputapparatus 542 and transmit output to the display apparatus 530. Further,the computing apparatus 540 may include data storage that may allow foraccess to processing programs or routines and/or one or more other typesof data, e.g., for calibrating and/or delivering pacing therapy fordriving a graphical user interface configured to noninvasively assist auser in targeting placement of a pacing device, and/or for evaluatingpacing therapy at that location (e.g., the location of an implantableelectrode used for pacing, the location of pacing therapy delivered by aparticular pacing vector, etc.).

The computing apparatus 540 may be operatively coupled to the inputapparatus 542 and the display apparatus 530 to, e.g., transmit data toand from each of the input apparatus 542 and the display apparatus 530.For example, the computing apparatus 540 may be electrically coupled toeach of the input apparatus 542 and the display apparatus 530 using,e.g., analog electrical connections, digital electrical connections,wireless connections, bus-based connections, network-based connections,internet-based connections, etc. As described further herein, a user mayprovide input to the input apparatus 542 to manipulate, or modify, oneor more graphical depictions displayed on the display apparatus 530 andto view and/or select one or more pieces of information related to thecardiac therapy.

Although as depicted the input apparatus 542 is a keyboard, it is to beunderstood that the input apparatus 542 may include any apparatuscapable of providing input to the computing apparatus 540 for performingthe functionality, methods, and/or logic described herein. For example,the input apparatus 542 may include a mouse, a trackball, a touchscreen(e.g., capacitive touchscreen, a resistive touchscreen, a multi-touchtouchscreen, etc.), etc. Likewise, the display apparatus 530 may includeany apparatus capable of displaying information to a user, such as agraphical user interface 532 including cardiac information, textualinstructions, graphical depictions of electrical activation information,graphical depictions of anatomy of a human heart, images or graphicaldepictions of the patient's heart, graphical depictions of a leadlesspacing device used to calibrate and/or deliver pacing therapy, graphicaldepictions of a leadless pacing device being positioned or placed toprovide cardiac pacing therapy, graphical depictions of locations of oneor more electrodes, graphical depictions of a human torso, images orgraphical depictions of the patient's torso, graphical depictions oractual images of implanted electrodes and/or leads, etc. Further, thedisplay apparatus 530 may include a liquid crystal display, an organiclight-emitting diode screen, a touchscreen, a cathode ray tube display,etc.

The processing programs or routines stored and/or executed by thecomputing apparatus 540 may include programs or routines forcomputational mathematics, matrix mathematics, dispersion determinations(e.g., standard deviations, variances, ranges, interquartile ranges,mean absolute differences, average absolute deviations, etc.), filteringalgorithms, maximum value determinations, minimum value determinations,threshold determinations, moving windowing algorithms, decompositionalgorithms, compression algorithms (e.g., data compression algorithms),calibration algorithms, image construction algorithms, signal processingalgorithms (e.g., various filtering algorithms, Fourier transforms, fastFourier transforms, etc.), standardization algorithms, comparisonalgorithms, vector mathematics, or any other processing required toimplement one or more methods and/or processes described herein. Datastored and/or used by the computing apparatus 540 may include, forexample, electrical signal/waveform data from the electrode apparatus510, dispersions signals, windowed dispersions signals, parts orportions of various signals, electrical activation times from theelectrode apparatus 510, graphics (e.g., graphical elements, icons,buttons, windows, dialogs, pull-down menus, graphic areas, graphicregions, 3D graphics, etc.), graphical user interfaces, results from oneor more processing programs or routines employed according to thedisclosure herein (e.g., electrical signals, cardiac information, etc.),or any other data that may be necessary for carrying out the one and/ormore processes or methods described herein.

Electrical activation times of the patient's heart may be useful toevaluate a patient's cardiac condition and/or to calibrate, deliver, orevaluate cardiac therapy to be or being delivered to a patient.Surrogate electrical activation information or data of one or moreregions of a patient's heart may be monitored, or determined, usingelectrode apparatus 510 as shown in FIGS. 9-11 . The electrode apparatus510 may be configured to measure body-surface potentials of a patient520 and, more particularly, torso-surface potentials of the patient 520.

As shown in FIG. 10 , the electrode apparatus 510 may include a set, orarray, of electrodes 512, a strap 513, and interface/amplifier circuitry516. A portion of the set of electrodes may be used wherein the portioncorresponds to a particular location on the patient's heart. Theelectrodes 512 may be attached, or coupled, to the strap 513, and thestrap 513 may be configured to be wrapped around the torso of a patient520 such that the electrodes 512 surround the patient's heart. Asfurther illustrated, the electrodes 512 may be positioned around thecircumference of a patient 520, including the posterior, lateral,posterolateral, anterolateral, and anterior locations of the torso of apatient 520.

Further, the electrodes 512 may be electrically connected tointerface/amplifier circuitry 516 via wired connection 518. Theinterface/amplifier circuitry 516 may be configured to amplify thesignals from the electrodes 512 and provide the signals to the computingapparatus 540. Other systems may use a wireless connection to transmitthe signals sensed by electrodes 512 to the interface/amplifiercircuitry 516 and, in turn, the computing apparatus 540, e.g., aschannels of data. For example, the interface/amplifier circuitry 516 maybe electrically coupled to each of the computing apparatus 540 and thedisplay apparatus 530 using, e.g., analog electrical connections,digital electrical connections, wireless connections, bus-basedconnections, network-based connections, internet-based connections, etc.

Although in the example of FIG. 10 the electrode apparatus 510 includesa strap 513, in other examples any of a variety of mechanisms, e.g.,tape or adhesives, may be employed to aid in the spacing and placementof electrodes 512. In some examples, the strap 513 may include anelastic band, strip of tape, or cloth. In other examples, the electrodes512 may be placed individually on the torso of a patient 520. Further,in other examples, electrodes 512 (e.g., arranged in an array) may bepart of, or located within, patches, vests, and/or other manners ofsecuring the electrodes 512 to the torso of the patient 520.

The electrodes 512 may be configured to surround the heart of thepatient 520 and record, or monitor, the electrical signals associatedwith the depolarization and repolarization of the heart after thesignals have propagated through the torso of a patient 520. Each of theelectrodes 512 may be used in a unipolar configuration to sense thetorso-surface potentials that reflect the cardiac signals. Theinterface/amplifier circuitry 516 may also be coupled to a return orindifferent electrode (not shown) that may be used in combination witheach electrode 512 for unipolar sensing. In some examples, there may beabout 12 to about 50 electrodes 512 spatially distributed around thetorso of the patient. Other configurations may have more or fewerelectrodes 512.

The computing apparatus 540 may record and analyze the electricalactivity (e.g., torso-surface potential signals) sensed by electrodes512 and amplified/conditioned by the interface/amplifier circuitry 516.The computing apparatus 540 may be configured to analyze the signalsfrom the electrodes 512 to provide as anterior and posterior electrodesignals and surrogate cardiac electrical activation times, e.g.,representative of actual, or local, electrical activation times of oneor more regions of the patient's heart as will be further describedherein. The computing apparatus 540 may be configured to analyze thesignals from the electrodes 512 to provide as anterior-septal electrodesignals and surrogate cardiac electrical activation times, e.g.,representative of actual, or local, electrical activation times of oneor more anterior-septal regions of the patient's heart, as will befurther described herein, e.g., for use in calibrating, delivering,and/or evaluating pacing therapy. Further, the electrical signalsmeasured at the left anterior surface location of a patient's torso maybe representative, or surrogates, of electrical signals of the leftanterior left ventricle region of the patient's heart, electricalsignals measured at the left lateral surface location of a patient'storso may be representative, or surrogates, of electrical signals of theleft lateral left ventricle region of the patient's heart, electricalsignals measured at the left posterolateral surface location of apatient's torso may be representative, or surrogates, of electricalsignals of the posterolateral left ventricle region of the patient'sheart, and electrical signals measured at the posterior surface locationof a patient's torso may be representative, or surrogates, of electricalsignals of the posterior left ventricle region of the patient's heart.Measurement of activation times can be performed by measuring the periodof time between an onset of cardiac depolarization (e.g., onset of QRScomplex) and an appropriate fiducial point such as, e.g., a peak value,a minimum value, a minimum slope, a maximum slope, a zero crossing, athreshold crossing, etc.

Additionally, the computing apparatus 540 may be configured to providegraphical user interfaces depicting the surrogate electrical activationtimes obtained using the electrode apparatus 510. Systems, methods,and/or interfaces may noninvasively use the electrical informationcollected using the electrode apparatus 510 to evaluate a patient'scardiac condition and/or to calibrate, deliver, or evaluate cardiacpacing therapy to be or being delivered to the patient.

FIG. 11 illustrates another electrode apparatus 510 that includes aplurality of electrodes 512 configured to surround the heart of thepatient 520 and record, or monitor, the electrical signals associatedwith the depolarization and repolarization of the heart after thesignals have propagated through the torso of the patient 520. Theelectrode apparatus 510 may include a vest 514 upon which the pluralityof electrodes 512 may be attached, or to which the electrodes 512 may becoupled. The plurality, or array, of electrodes 512 may be used tocollect electrical information such as, e.g., surrogate electricalactivation times.

Similar to the electrode apparatus 510 of FIG. 10 , the electrodeapparatus 510 of FIG. 11 may include interface/amplifier circuitry 516electrically coupled to each of the electrodes 512 through a wiredconnection 518 and be configured to transmit signals from the electrodes512 to computing apparatus 540. As illustrated, the electrodes 512 maybe distributed over the torso of a patient 520, including, for example,the anterior, lateral, posterolateral, anterolateral, and posteriorsurfaces of the torso of the patient 520.

The vest 514 may be formed of fabric with the electrodes 512 attached tothe fabric. The vest 514 may be configured to maintain the position andspacing of electrodes 512 on the torso of the patient 520. Further, thevest 514 may be marked to assist in determining the location of theelectrodes 512 on the surface of the torso of the patient 520. The vest514 may include about 17 or more anterior electrodes positionableproximate the anterior torso of the patient, and about 39 or moreposterior electrodes positionable proximate the posterior torso of thepatient. In some examples, there may be about 25 electrodes 512 to about256 electrodes 512 distributed around the torso of the patient 520,though other configurations may have more or fewer electrodes 512.

As described herein, the electrode apparatus 510 may be configured tomeasure electrical information (e.g., electrical signals) representingdifferent regions of a patient's heart. For example, activation times ofdifferent regions of a patient's heart can be approximated from surfaceelectrocardiogram (ECG) activation times measured using surfaceelectrodes in proximity to surface areas corresponding to the differentregions of the patient's heart. In at least one example, activationtimes of the anterior-septal region of a patient's heart can beapproximated from surface ECG activation times measured using surfaceelectrodes in proximity to surface areas corresponding to theanterior-septal region of the patient's heart. That is, a portion of theset of electrodes 512, and not the entire set, can be used to generateactivation times corresponding to a particular location of the patient'sheart that the portion of the set of electrodes corresponds to.

The systems, methods, and interfaces may be used to provide noninvasiveassistance to a user in the evaluation of a patient's cardiac health orstatus, and/or the evaluation of cardiac therapy such as CRT by use ofthe electrode apparatus 510 (e.g., cardiac therapy beingpresently-delivered to a patient during implantation or afterimplantation). Further, the systems, methods, and interfaces may be usedto assist a user in the configuration, or calibration, of the cardiactherapy, such as CRT, to be or being delivered to a patient.

Electrical activity may be monitored using a plurality of externalelectrodes, such as electrodes 512 of FIGS. 9-11 . The electricalactivity can be monitored by a plurality of electrodes during pacingtherapy or in the absence of pacing therapy. The monitored electricalactivity can be used to evaluate pacing therapy to a patient. Theelectrical activity monitored using the ECG belt described can be usedto evaluate at least one paced setting of the pacing therapy on theheart. As an example, a paced setting can be any one parameter or acombination of parameters including, but not limited to, electrodeposition, pacing polarity, pacing output, pacing pulse width, timing atwhich ventricular pacing is delivered relative to atrial timing, pacingrate, etc. Further, as an example, the location of the leadless deviceor a pacing lead can include a location in the right ventricle, leftventricle, or right atrium.

Further, body-surface isochronal maps of ventricular activation can beconstructed using the monitored electrical activity during pacingtherapy or in the absence of pacing therapy. The monitored electricalactivity and/or the map of ventricular activation can be used togenerate electrical heterogeneity information (EHI). The electricalheterogeneity information can include determining metrics of electricalheterogeneity. The metrics of electrical heterogeneity can include ametric of standard deviation of activation times (SDAT) of electrodes ona left side of a torso of the patient and/or a metric of mean leftventricular activation time (LVAT) of electrodes on the left side of thetorso of the patient. A metric of LVAT may be determined from electrodeson both the anterior and posterior surfaces, which are more proximal tothe left ventricle. The metrics of electrical heterogeneity informationcan include a metric of mean right ventricular activation time (RVAT) ofelectrodes on the right side of the torso of the patient. A metric ofRVAT may be determined from electrodes on both the anterior andposterior surfaces which are more proximal to the right ventricle. Themetrics of electrical heterogeneity can include a metric of mean totalactivation time (mTAT) taken from a plurality of electrode signals fromboth sides of the torso of the patient, or it may include other metrics(e.g., standard deviation, interquartile deviations, a differencebetween a latest activation time and earliest activation time)reflecting a range or dispersion of activation times on a plurality ofelectrodes located on the right side of the patient torso or left sideof the patient torso, or combining both right and left sides of thepatient torso. The metrics of electrical heterogeneity information caninclude a metric of anterior-septal activation times (ASAT) ofelectrodes on the torso in close proximity to the anterior-septalportion of the heart.

Electrical heterogeneity information (EHI) may be generated duringdelivery of pacing therapy at one or more paced settings. The electricalheterogeneity information can be generated using metrics of electricalheterogeneity. As an example, the metrics of electrical heterogeneitycan include one or more of an SDAT, an LVAT, an RVAT, an mTAT, and anASAT. In another example, only ASAT may be determined and further used,and/or ASAT may be more heavily weighted than other values.

One or more paced settings associated with the pacing therapy may beevaluated. A paced setting can include a plurality of pacing parameters.The plurality of pacing parameters can be optimal if the patient'scardiac condition improves, if the pacing therapy is effectivelycapturing a desired portion of the RA, RV, or LV, and/or if a metric ofelectrical heterogeneity improves by a certain threshold compared to abaseline rhythm or therapy. The determination of whether the pacedsetting is optimal can be based on at least one metric of electricalheterogeneity generated from electrical activity during pacing (andalso, in some cases, during native conduction, or in the absence ofpacing). The at least one metric can include one or more of an SDAT, anLVAT, an RVAT, an mTAT, and an ASAT.

Further, the plurality of pacing parameters can be optimal if a metricof electrical heterogeneity is greater than or less than a particularthreshold, and/or if the location of the pacing therapy to excite theleft ventricle causes a particular pattern of excitation of the musclefibers in the heart. In addition, the plurality of pacing parameters canbe optimal if a metric of electrical heterogeneity indicates acorrection of a left bundle branch block (LBBB), and/or if a metric ofelectrical heterogeneity indicates a complete engagement of a Purkinjesystem, etc. As an example, a metric of electrical heterogeneity of anASAT less than or equal to a threshold (e.g., a threshold of 30 ms) andan LVAT less than or equal to a threshold (e.g., a threshold of 30 ms)can indicate a correction of an LBBB, and thus, the paced setting isoptimal. As an example, a metric of electrical heterogeneity of an RVATless than or equal to a threshold (e.g., a threshold of 30 ms), an ASATless than or equal to a threshold (e.g., a threshold of 30 ms), and anLVAT less than or equal to a threshold (e.g., a threshold of 30 ms) canindicate a complete engagement of the Purkinje system, and thus thepaced setting is may be optimal.

The paced setting can be determined to be optimal in response to thepacing therapy using the paced setting being acceptable, beingbeneficial, being indicative of complete engagement of patient's nativecardiac conduction system, being indicative of correction of aventricular conduction disorder (e.g., left bundle branch block), etc. Apaced setting can include one or more of a pacing electrode position(including one or more of a depth, an angle, an amount of turn for ascrew-based fixation mechanism, etc.), a voltage, a pulse width, anintensity, a pacing polarity, a pacing vector, a pacing waveform, atiming of the pacing delivered relative to an intrinsic or paced atrialevent or relative to the intrinsic His bundle potential, and/or a pacinglocation, etc. A pacing vector can include any two or more pacingelectrodes such as, e.g., a tip electrode to a can electrode, a tipelectrode to a ring electrode etc., that are used to deliver the pacingtherapy, etc. The pacing location can refer to the location of any ofthe one or more pacing electrodes that are positioned using a lead, aleadless device, and/or any device or apparatus configured to deliverpacing therapy.

A paced setting for therapy may be adjusted. The paced setting can beadjusted in response to the paced setting being not optimal. The pacedsetting can be adjusted in response to the paced setting being within anoptimal range but in order to determine whether the paced setting can beat a position within the optimal range that is more beneficial, moreuseful, more functional, etc., for the pacing therapy. The paced settingcould be adjusted to find the most optimal metric of electricalheterogeneity.

A determination of whether the paced setting is optimal can be based ona particular metric of electrical heterogeneity using an ECG belt. In atleast one example, the paced setting can be adjusted at intervals thatcorrelate with a change in the metric of electrical heterogeneity untilthe metric of electrical heterogeneity is at or proximate a particularmetric value. For instance, the adjusting of the paced setting can causethe metric of electrical heterogeneity to approach a particularthreshold metric of electrical heterogeneity and, as the metricapproaches the particular threshold, the rate at which the paced settingis adjusted can be slowed down. Put another way, as the metric ofelectrical heterogeneity is further from the particular thresholdmetric, the paced setting can be adjusted more quickly and as the metricof electrical heterogeneity gets closer to the particular thresholdmetric, the paced setting can be adjusted more slowly until the metricof electrical heterogeneity is at the particular threshold metric.

FIG. 12 shows one example of a method for use with the system 100 toprovide cardiac therapy, such as CRT. The method 600 may includeadvancing one or more electrodes toward an implant location 602. In oneexample, one or more electrodes may be advanced along a path through thesuperior vena cava (SVC) of the patient. The one or more electrodes maybe coupled to an intracardiac IMD or leaded IMD, such as describedherein with respect to FIGS. 1-8 .

The method 600 may also include implanting a first ventricular electrode604 of the one or more electrodes. The first ventricular electrode maybe an LV electrode, which may be implanted through the RV septum intothe myocardium of the LV septum.

A second ventricular electrode of the one or more electrodes may also beimplanted 606. The second ventricular electrode may be an RV electrode,which may be implanted into the myocardium of the RV septum orpositioned in contact with the endocardium of the RV septum. The firstand second ventricular electrodes may be used to monitor the electricalactivity of or to deliver cardiac therapy to one or both ventricles.

The method 600 may also include implanting an atrial electrode 608 ofthe one or more electrodes. The atrial electrode may be an RA electrode,which may be implanted into the myocardium of the RA or positioned incontact with the endocardium of the RA. The RA electrode may be operablycoupled to the same device, or a different device, as one or both of theventricular electrodes.

After one or more electrodes are initially positioned, electricalactivity may be monitored 610. For example, the atrial electrode may beused to monitor electrical activity of the RA, and the ventricularelectrodes may be used to monitor electrical activity of one or both ofthe LV and the RV for use in delivering and/or adjusting cardiactherapy.

The method 600 may include delivering cardiac therapy 612. Cardiactherapy may be delivered based on, or in response to, the monitoredelectrical activity 610 using the one or more electrodes. For example,AV synchronous pacing may be delivered to the RA, RV, and LV using theRA electrode, RV electrode, and LV electrode, respectively.

FIG. 13 shows one example of a method for use with the system 100 todetermine one or more implant locations for one or more of theelectrodes. The method 620 may include introducing a testing catheter toa potential implant location 622. The testing catheter may be operablycoupled to a testing device capable of monitoring electrical activityand delivering test pulses. Any suitable testing catheter and testingdevice may be used, such as one known to one skilled in the art havingthe benefit of this disclosure.

The testing catheter may include a testing electrode. The testingelectrode may be introduced along a retrograde path through the aorta ofthe patient to the LV. In particular, the testing electrode may beinserted into the myocardium of the LV septum to test one or morelocations. The testing catheter may be moved to different positionsalong the ventricular septal wall to test more than one location. Forexample, locations along the LV septum proximate to the base,mid-septal, and apex may be tested. Using the aorta for testing LVpacing location in the LV septum may be faster than testing using anelectrode that penetrates through the RV septum into the LV septum.

The method 620 may also include testing a pacing parameter or potentialimplant location 624. More than one location may be evaluated. A pacingparameter or location may be tested based on electrical activity, suchas EHI, provided by using an external electrode apparatus having aplurality of external electrodes, such as described herein with respectto FIGS. 9-11 .

The method 620 may include determining whether the pacing parameter orlocation is acceptable 626, for example, based on evaluating EHI thatwas generated from electrical activity monitored during delivery of thepacing using the pacing parameter or location. One or more pacingparameters or locations may also be compared to one another, and anoptimal pacing parameter or location may be selected.

If the pacing parameter or location is not acceptable, the method 620may include selecting a different pacing parameter or location 630. If adifferent location is selected, the method 620 may return to introducethe testing catheter at a new potential implant location 622 and testthe same or different pacing parameter at the new potential implantlocation. If a different pacing parameter is selected, the method 620may return to testing the different pacing parameter 624 at the samelocation.

If the pacing parameter or location is acceptable, the method 620 mayupdate the pacing parameter or location 628, respectively. Inparticular, the particular pacing parameter or location may be noted, orstored in data, and the testing catheter may be removed. Method 600 ofFIG. 12 may follow method 620. In particular, one or more electrodes maybe implanted through the SVC based on the updated pacing parameter orlocation determined in method 620.

ILLUSTRATIVE EMBODIMENTS

While the present disclosure is not so limited, an appreciation ofvarious aspects of the disclosure will be gained through a discussion ofthe specific illustrative embodiments provided below. Variousmodifications of the illustrative embodiments, as well as additionalembodiments of the disclosure, will become apparent herein.

In embodiment A1, a leadless implantable medical device for a patient'sheart includes:

-   -   an intracardiac housing implantable in the right ventricle of        the patient's heart;    -   a leadlet coupled to the intracardiac housing extendable through        the tricuspid valve of the patient's heart into the right atrium        of the patient's heart;    -   a plurality of electrodes coupled to one or both of the        intracardiac housing and the leadlet, the plurality of        electrodes including:        -   a ventricular electrode implantable in the ventricular            septal wall of the patient's heart to deliver cardiac            therapy to or sense electrical activity of the left            ventricle of the patient's heart; and        -   a right atrial electrode coupled to the leadlet and            implantable to deliver cardiac therapy to or sense            electrical activity of the right atrium of the patient's            heart;    -   a therapy delivery circuit operably coupled to the plurality of        electrodes to deliver cardiac therapy to the patient's heart;    -   a sensing circuit operably coupled to the plurality of        electrodes to sense electrical activity of the patient's heart;        and    -   a controller including processing circuitry operably coupled to        the therapy delivery circuit and the sensing circuit, the        controller configured to:        -   monitor electrical activity using one or both of the right            atrial electrode and the ventricular electrode; and        -   deliver cardiac therapy based on the monitored electrical            activity.

In embodiment A2, a device includes the device according to embodimentA1, wherein delivering cardiac therapy includes delivering cardiacresynchronization therapy.

In embodiment A3, a device includes the device according to embodimentA1 or A2, wherein the plurality of electrodes further includes a rightventricular electrode implantable in the right ventricle of thepatient's heart to deliver cardiac therapy to or sense electricalactivity of the right ventricle.

In embodiment A4, a device includes the device according to embodimentA3, further including a tissue-penetrating electrode assembly includingthe right ventricular electrode and the ventricular electrode distal tothe right ventricular electrode.

In embodiment A5, a device includes the device according to embodimentA3 or A4, wherein the right ventricular electrode is implantable at thebase of the patient's heart proximate to the right bundle branch and theventricular electrode is implantable at the base of the patient's heartproximate to the left bundle branch.

In embodiment A6, a device includes the device according to any one ofembodiments A1-A3, further including a tissue-penetrating electrodeassembly coupled to the intracardiac housing and including theventricular electrode, wherein the tissue-penetrating electrode assemblydoes not deliver the ventricular electrode into the blood volume of theleft ventricle.

In embodiment A7, a device includes the device according to any one ofembodiments A1-A3, further including a tissue-penetrating electrodeassembly having a helix electrode assembly including the ventricularelectrode.

In embodiment A8, a device includes the device according to any one ofembodiments A1-A3, further including a tissue-penetrating electrodeassembly having a dart electrode assembly including the ventricularelectrode.

In embodiment A9, a device includes the device according to anypreceding A embodiment, wherein the right atrial electrode isimplantable in the endocardium of the right atrium of the patient'sheart.

In embodiment A10, a device includes the device according to anypreceding A embodiment, wherein the ventricular electrode is implantablein the endocardium of the left ventricle of the patient's heart.

In embodiment A11, a device includes the device according to anypreceding A embodiment, wherein the ventricular electrode is implantablethrough the ventricular septal wall in the right ventricle into theendocardium of the left ventricle.

In embodiment A12, a device includes the device according to anypreceding A embodiment, wherein the ventricular electrode is implantablein the ventricular septal wall proximate to the apex of the patient'sheart, proximate to the mid-septal portion of the patient's heart, orproximate to the base of the patient's heart.

In embodiment A13, a device includes the device according to anypreceding A embodiment, further including a fixation assembly operablycoupled to the intracardiac housing couplable to the endocardium of theright ventricle.

In embodiment A14, a device includes the device according to anypreceding A embodiment, wherein the controller further includes awireless communication interface operably couplable to an extravascularimplantable medical device, wherein the controller is further configuredto monitor electrical activity using the extravascular implantablemedical device.

In embodiment A15, a device includes the device according to anypreceding A embodiment, wherein to deliver cardiac therapy, thecontroller is further configured to deliver three-chamber synchronouspacing for the left ventricle, the right ventricle, and the right atriumusing the plurality of electrodes.

In embodiment B1, an implantable medical system includes:

-   -   an intracardiac housing implantable in a right ventricle of a        patient's heart;    -   an implantable medical lead implantable into the right atrium of        a patient's heart;    -   a plurality of electrodes including:        -   a ventricular electrode coupled to the intracardiac housing            and implantable in the ventricular septal wall of the            patient's heart to deliver cardiac therapy to or sense            electrical activity of the left ventricle of the patient's            heart; and        -   a right atrial electrode coupled to the lead and implantable            to deliver cardiac therapy to or sense electrical activity            of the right atrium of the patient's heart;    -   a first controller contained in the intracardiac housing and        including processing circuitry operably coupled to the        ventricular electrode; and    -   a second controller coupled to the implantable medical lead and        including processing circuitry operably coupled to the right        atrial electrode;    -   wherein the first controller is configured to wirelessly        communicate with the second controller to:        -   monitor electrical activity using one or both of the right            atrial electrode and the ventricular electrode; and        -   deliver cardiac therapy based on the monitored electrical            activity.

In embodiment B2, a system includes the system according to embodimentB1, further including a plurality of external electrodes to provideelectrical heterogeneity information.

In embodiment B3, a system includes the system according to embodimentB1 or B2, wherein delivering cardiac therapy includes delivering cardiacresynchronization therapy.

In embodiment B4, a system includes the system according to anypreceding B embodiment, further including a right ventricular electrodecoupled to the intracardiac housing and implantable to deliver cardiactherapy to or sense electrical activity of the right ventricle of thepatient's heart.

In embodiment B5, the system includes the system according to embodimentB4, further including a tissue-penetrating electrode assembly comprisingthe right ventricular electrode and the ventricular electrode distal tothe right ventricular electrode.

In embodiment B6, a system includes the system according to embodimentB4 or B5, wherein the right ventricular electrode is implantable at thebase of the patient's heart proximate to the right bundle branch and theventricular electrode is implantable at the base of the patient's heartproximate to the left bundle branch.

In embodiment B7, a system includes the system according to any one ofembodiments B1-B4, further including a tissue-penetrating electrodeassembly coupled to the intracardiac housing and including theventricular electrode, wherein the tissue-penetrating electrode assemblydoes not deliver the ventricular electrode into the blood volume of theleft ventricle.

In embodiment B8, a system includes the system according to any one ofembodiments B1-B4, further including a tissue-penetrating electrodeassembly having a helix electrode assembly including the ventricularelectrode.

In embodiment B9, a system includes the system according to any one ofembodiments B1-B4, further including a tissue-penetrating electrodeassembly having a dart electrode assembly including the ventricularelectrode.

In embodiment B10, a system includes the system according to anypreceding B embodiment, wherein the right atrial electrode isimplantable in the endocardium of the right atrium of the patient'sheart.

In embodiment B11, a system includes the system according to anypreceding B embodiment, wherein the ventricular electrode is implantablein the endocardium of the left ventricle of the patient's heart.

In embodiment B12, a system includes the system according to anypreceding B embodiment, wherein the ventricular electrode is implantablethrough the ventricular septal wall in the right ventricle into theendocardium of the left ventricle.

In embodiment B13, a system includes the system according to anypreceding B embodiment, wherein the ventricular electrode is implantablein the ventricular septal wall proximate to the apex of the patient'sheart, proximate to the mid-septal portion of the patient's heart, orproximate to the base of the patient's heart.

In embodiment B14, a system includes the system according to anypreceding B embodiment, further including a fixation assembly operablycoupled to the intracardiac housing couplable to the endocardium of theright ventricle.

In embodiment B15, a system includes the system according to anypreceding B embodiment, wherein to deliver cardiac therapy, the firstcontroller is further configured to wirelessly communicate with thesecond controller to deliver three-chamber synchronous pacing for theleft ventricle, the right ventricle, and the right atrium using theplurality of electrodes.

In embodiment C1, an implantable medical device includes:

-   -   an implantable medical housing for a patient's heart;    -   a first medical lead coupled to the implantable medical housing        and implantable in the ventricular septal wall through the right        ventricle of the patient's heart;    -   a second medical lead coupled to the implantable medical housing        and implantable in the right atrium of the patient's heart;    -   a plurality of electrodes including:        -   a left ventricular electrode coupled to the first medical            lead and implantable in the ventricular septal wall of the            patient's heart to deliver cardiac therapy to or sense            electrical activity of the left ventricle of the patient's            heart;        -   a right ventricular electrode coupled to the first medical            lead and implantable in the ventricular septal wall of the            patient's heart to deliver cardiac therapy to or sense            electrical activity of the right ventricle of the patient's            heart; and        -   a right atrial electrode coupled to the second medical lead            and implantable to deliver cardiac therapy to or sense            electrical activity of the right atrium of the patient's            heart; and    -   a controller including processing circuitry operably coupled to        the ventricular electrode and to the right atrial electrode, the        controller configured to:        -   monitor electrical activity using one or more of the left            ventricular electrode, the right ventricular electrode, and            the right atrial electrode; and        -   deliver cardiac therapy based on the monitored electrical            activity.

In embodiment C2, a device includes the device according to embodimentC1, wherein to deliver cardiac therapy, the controller is furtherconfigured to deliver three-chamber synchronous pacing for the leftventricle, the right ventricle, and the right atrium using the firstmedical lead and the second medical lead.

In embodiment C3, a device includes the device according to embodimentC1 or C2, wherein delivering cardiac therapy includes delivering cardiacresynchronization therapy.

In embodiment C4, a device includes the device according to anypreceding C embodiment, further including a tissue-penetrating electrodeassembly including the right ventricular electrode and the leftventricular electrode distal to the right ventricular electrode.

In embodiment C5, a device includes the device according to anypreceding C embodiment, wherein the right ventricular electrode isimplantable at the base of the patient's heart proximate to the rightbundle branch and the left ventricular electrode is implantable at thebase of the patient's heart proximate to the left bundle branch.

In embodiment C6, a device includes the device according to any one ofembodiments C1-C3, further including a tissue-penetrating electrodeassembly coupled to the first medical lead including the leftventricular electrode, wherein the tissue-penetrating electrode assemblydoes not deliver the left ventricular electrode into the blood volume ofthe left ventricle.

In embodiment C7, a device includes the device according to any one ofembodiments C1-C3, further including a tissue-penetrating electrodeassembly having a helix electrode assembly including the leftventricular electrode.

In embodiment C8, a device includes the device according to any one ofembodiments C1-C3, further comprising a tissue-penetrating electrodeassembly having a dart electrode assembly including the left ventricularelectrode.

In embodiment C9, a device includes the device according to anypreceding C embodiment, wherein the right atrial electrode isimplantable in the endocardium of the right atrium of the patient'sheart.

In embodiment C10, a device includes the device according to anypreceding C embodiment, wherein the left ventricular electrode isimplantable in the endocardium of the left ventricle of the patient'sheart.

In embodiment C11, a device includes the device according to anypreceding C embodiment, wherein the left ventricular electrode isimplantable through the ventricular septal wall in the right ventricleinto the endocardium of the left ventricle.

In embodiment C12, a device includes the device according to anypreceding C embodiment, wherein the left ventricular electrode isimplantable in the ventricular septal wall proximate to the apex of thepatient's heart, proximate to the mid-septal portion of the patient'sheart, or proximate to the base of the patient's heart.

In embodiment C13, a device includes the device according to anypreceding C embodiment, further including a fixation assembly operablycoupled to the first medical lead couplable to the endocardium of theright ventricle.

In embodiment C14, a device includes the device according to anypreceding C embodiment, wherein the controller further includes awireless communication interface operably couplable to an extravascularimplantable medical device, wherein the controller is further configuredto monitor electrical activity using the extravascular implantablemedical device.

In embodiment D1, a method includes:

-   -   implanting a ventricular electrode coupled to an intracardiac        housing or a first medical lead to the ventricular septal wall        of a patient's heart to deliver cardiac therapy to or sense        electrical activity of the ventricle of the patient's heart;    -   implanting a right atrial electrode coupled to a leadlet or a        second medical lead in the right atrium of the patient's heart        to deliver cardiac therapy to or sense electrical activity of        the right atrium of the patient's heart;    -   monitoring electrical activity using the ventricular electrode,        the right atrial electrode, or both; and    -   delivering cardiac therapy based on the monitored electrical        activities using at least one of the ventricular electrode or        the right atrial electrode.

In embodiment D2, a method includes the method according to embodimentD1, further including:

-   -   testing a pacing parameter or location of the ventricular        electrode at a potential implant location using electrical        activity monitored by a plurality of external electrodes; and    -   updating the pacing parameter or location of the ventricular        electrode based on the testing.

In embodiment D3, a method includes the method according to embodimentD2, further including introducing a testing catheter along a retrogradepath through the aorta of the patient to the left ventricle, whereintesting the pacing parameter or location of the ventricular electrodeincludes evaluating different locations of the testing catheter alongthe ventricular septal wall.

In embodiment D4, a method includes the method according to anypreceding D embodiment, further including implanting a right ventricularelectrode coupled to the intracardiac housing or the first medical leadto the ventricular septal wall of a patient's heart to deliver cardiactherapy to or sense electrical activity of the ventricle of thepatient's heart.

In embodiment D5, a method includes the method according to anypreceding D embodiment, further including delivering one or more of theelectrodes along a path through the superior vena cava of the patient.

Thus, IMPLANTABLE MEDICAL SYSTEMS AND METHODS FOR AV SYNCHRONOUS SEPTALPACING are disclosed. Although reference is made herein to theaccompanying set of drawings that form part of this disclosure, one ofat least ordinary skill in the art will appreciate that variousadaptations and modifications are within, or do not depart from, thescope of this disclosure. For example, parts of the systems, apparatus,devices, methods, and the like described herein may be combined in avariety of ways with each other. Therefore, it is to be understood that,within the scope of the appended claims, the claimed invention may bepracticed other than as explicitly described herein.

It should be understood that various aspects disclosed herein may becombined in different combinations than the combinations specificallypresented in the description and accompanying drawings. It should alsobe understood that, depending on the example, certain acts or events ofany of the processes or methods described herein may be performed in adifferent sequence, may be added, merged, or left out altogether (e.g.,all described acts or events may not be necessary to carry out thetechniques). In addition, while certain aspects of this disclosure aredescribed as being performed by a single module or unit for purposes ofclarity, it should be understood that the techniques of this disclosuremay be performed by a combination of units or modules associated with,for example, a medical device.

The described techniques may be implemented in hardware, software,firmware, or any combination thereof. If implemented in software, thefunctions may be stored as one or more instructions or code on acomputer-readable medium and executed by a hardware-based processingunit. Computer-readable media may include non-transitorycomputer-readable media, which corresponds to a tangible medium such asdata storage media (e.g., RAM, ROM, EEPROM, flash memory, or any othermedium that can be used to store desired program code in the form ofinstructions or data structures and that can be accessed by a computer).

Instructions may be executed by one or more processors, such as one ormore digital signal processors (DSPs), general purpose microprocessors,application specific integrated circuits (ASICs), field programmablelogic arrays (FPGAs), or other equivalent integrated or discrete logiccircuitry. Accordingly, the term “processor” as used herein may refer toany of the foregoing structure or any other physical structure suitablefor implementation of the described techniques. Also, the techniquescould be fully implemented in one or more circuits or logic elements.

All references and publications cited herein are expressly incorporatedherein by reference in their entirety for all purposes, except to theextent any aspect directly contradicts this disclosure.

All scientific and technical terms used herein have meanings commonlyused in the art unless otherwise specified. The definitions providedherein are to facilitate understanding of certain terms used frequentlyherein and are not meant to limit the scope of the present disclosure.

Unless otherwise indicated, all numbers expressing feature sizes,amounts, and physical properties used in the specification and claimsmay be understood as being modified either by the term “exactly” or“about.” Accordingly, unless indicated to the contrary, the numericalparameters set forth in the foregoing specification and attached claimsare approximations that can vary depending upon the desired propertiessought to be obtained by those skilled in the art utilizing theteachings disclosed herein or, for example, within typical ranges ofexperimental error.

The recitation of numerical ranges by endpoints includes all numberssubsumed within that range (e.g. 1 to 5 includes 1, 1.5, 2, 2.75, 3,3.80, 4, and 5) and any range within that range. Herein, the terms “upto” or “no greater than” a number (e.g., up to 50) includes the number(e.g., 50), and the term “no less than” a number (e.g., no less than 5)includes the number (e.g., 5).

Terms related to orientation, such as “proximal” or “distal,” are usedto describe relative positions of components and are not meant to limitthe orientation of the components described.

As used herein, the term “configured to” may be used interchangeablywith the terms “adapted to” or “structured to” unless the content ofthis disclosure clearly dictates otherwise.

Th singular forms “a,” “an,” and “the” encompass singular and pluralreferents unless its context clearly dictates otherwise.

The phrases “at least one of,” “comprises at least one of,” and “one ormore of” followed by a list refers to any one of the items in the listand any combination of two or more items in the list.

As used herein, “have,” “having,” “include,” “including,” “comprise,”“comprising” or the like are used in their open-ended sense, andgenerally mean “including, but not limited to.” It will be understoodthat “consisting essentially of,” “consisting of,” and the like aresubsumed in “comprising,” and the like.

What is claimed is:
 1. An implantable medical device comprising: animplantable medical housing; a first medical lead coupled to theimplantable medical housing and implantable in the right ventricle of apatient's heart, wherein the first medical lead comprises a fixationassembly, wherein the fixation assembly comprises: a tissue-penetratingelectrode assembly comprising a right ventricular electrode and a leftventricular electrode distal to the right ventricular electrode, whereinthe left ventricular electrode is implantable in the ventricular septalwall of the patient's heart to deliver cardiac therapy to or senseelectrical activity of the left ventricle of the patient's heart; andwherein the right ventricular electrode is implantable in theventricular septal wall of the patient's heart to deliver cardiactherapy to or sense electrical activity of the right ventricle of thepatient's heart; a second medical lead coupled to the implantablemedical housing and implantable in the right atrium of the patient'sheart, wherein the second medical lead comprises a right atrialelectrode implantable to deliver cardiac therapy to or sense electricalactivity of the right atrium of the patient's heart; and a controllercomprising processing circuitry operably coupled to the left ventricularelectrode, the right ventricular electrode, and the right atrialelectrode, the controller configured to: monitor electrical activityusing one or more of the left ventricular electrode, the rightventricular electrode, and the right atrial electrode; and delivercardiac therapy based on the monitored electrical activity.
 2. Thedevice according to claim 1, wherein to deliver cardiac therapy, thecontroller is further configured to deliver three-chamber synchronouspacing for the left ventricle, the right ventricle, and the right atriumusing the first medical lead and the second medical lead.
 3. The deviceaccording to claim 1, wherein delivering cardiac therapy comprisesdelivering cardiac resynchronization therapy.
 4. The device according toclaim 1, wherein the tissue-penetrating electrode assembly does notdeliver the left ventricular electrode into the blood volume of the leftventricle.
 5. The device according to claim 1, wherein the rightventricular electrode is implantable at the base of the patient's heartproximate to the right bundle branch and the left ventricular electrodeis implantable at the base of the patient's heart proximate to the leftbundle branch.
 6. The device according to claim 1, wherein the firstmedical lead comprises a helix comprising at least the left ventricularelectrode.
 7. The device according to claim 1, further comprising a dartelectrode assembly coupled to the first medical lead including the leftventricular electrode.
 8. The device according to claim 1, wherein theright atrial electrode is implantable in the endocardium of the rightatrium of the patient's heart.
 9. The device according to claim 1,wherein the left ventricular electrode is implantable in the endocardiumof the left ventricle of the patient's heart.
 10. The device accordingto claim 1, wherein the left ventricular electrode is implantablethrough the ventricular septal wall in the right ventricle into theendocardium of the left ventricle.
 11. The device according to claim 1,wherein the left ventricular electrode is implantable in the ventricularseptal wall proximate to the apex of the patient's heart, proximate tothe mid-septal portion of the patient's heart, or proximate to the baseof the patient's heart.
 12. The device according to claim 1, wherein thecontroller further comprises a wireless communication interface operablycouplable to an extravascular implantable medical device, wherein thecontroller is further configured to monitor electrical activity usingthe extravascular implantable medical device.
 13. A method comprising:implanting a ventricular electrode coupled to an intracardiac housing ora first medical lead to the ventricular septal wall of a patient's heartto deliver cardiac therapy to or sense electrical activity of aventricle of the patient's heart; implanting a right atrial electrodecoupled to a leadlet or a second medical lead in the right atrium of thepatient's heart to deliver cardiac therapy to or sense electricalactivity of the right atrium of the patient's heart; monitoringelectrical activity using the ventricular electrode, the right atrialelectrode, or both; testing a pacing parameter or location of theventricular electrode at a potential implant location using electricalheterogeneity information monitored by a plurality of externalelectrodes; updating the pacing parameter or location of the ventricularelectrode based on the testing; and delivering cardiac therapy based onthe monitored electrical activities using at least one of theventricular electrode or the right atrial electrode.
 14. The methodaccording to claim 13, further comprising introducing a testing catheteralong a retrograde path through the aorta of the patient to the leftventricle, wherein testing the pacing parameter or location of theventricular electrode comprises evaluating different locations of thetesting catheter along the ventricular septal wall.
 15. The methodaccording to claim 13, further comprising implanting a right ventricularelectrode coupled to the intracardiac housing or the first medical leadto the ventricular septal wall of a patient's heart to deliver cardiactherapy to or sense electrical activity of the ventricle of thepatient's heart.
 16. The method according to claim 13, furthercomprising delivering one or more of the electrodes along a path throughthe superior vena cava of the patient.